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Normal Growth & Cartilage SPR 2017 Musculoskeletal Imaging Categorical Course: Normal Growth & Cartilage May 19, 2017 SAM References Normal Growth and Growth Cartilage Diego Jaramillo, MD, MPH 1. A 12-year-old boy with a history of a fracture of the distal tibia 10 months earlier undergoes an MRI for evaluation of the distal tibial and fibular physes. Signs of a bony bridge with growth arrest include all except: A. Interruption of the physeal cartilage B. Interruption of the zone of provisional calcification C. Growth recovery line parallel to the physis D. Deformity in varus Correct Answer: C Rationale Following an injury to the physis, there is a slowdown of growth related to decreased activity during immobilization. This results in increased mineralization of the metaphyseal side of the physeal cartilage. With resumption of growth, the physis leaves behind this disc of mineralized cartilage, so that a line becomes visible. This line is sclerotic on radiographs and of low signal intensity on MR images and indicates the position of the physis at the time of injury. The mechanism is similar to the formation of a ring on a tree during the slowdown of growth that occurs every winter. This growth recovery line has also been called a growth arrest line and is commonly referred to as a Harris line by Orthopaedic surgeons. If the physis is intact, all of the cartilage will migrate away from the growth recovery line and they will be parallel to each other. If there is a focal area of growth arrest, the physis will be tethered by the bony bridge. The abnormal physis will be unable to migrate away from the growth recovery line at the bony bridge, whereas it will move away from the physis in the regions that have more normal growth. The physis will thus converge with the growth recovery line at the site of the bridge but will be distant from the line where the cartilage is more normal. Answers A and B are incorrect. Explanation: A bony bridge after physeal injury results in interruption of the physeal cartilage and of the zone of provisional calcification, so A and B are true. Answer D is incorrect. Explanation: The abnormal growth will often lead to angular deformity so D is true. References 1. Shailam R, Jaramillo D, Kan JH. Growth arrest and leg-length discrepancy. Pediatr Radiol. 2013 Mar;43 Suppl 1:S155-65. 2. Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012 Jul 3;94(13):1234-44. 3. Ecklund K, Jaramillo D. Patterns of premature physeal arrest: MR imaging of 111 children. AJR Am J Roentgenol. 2002 Apr;178(4):967-72. 2. A 10-year-old girl has an MRI of the knee for evaluation of trauma. On the fat-suppressed proton density images, the high signal intensity of the physeal cartilage extends into the metaphysis, and the zone of provisional calcification is poorly defined. Extension of cartilage from the physis into the metaphysis can be seen in the following except: A. Chronic sports injury B. Scurvy C. Metaphyseal infarct D. Non-accidental trauma E. Rickets Correct Answer: B Rationale Normal endochondral ossification occurs when the chondrocytes from the hypertrophic zone of the physis undergo normal apoptosis. The integrity of the metaphysis, particularly of the metaphyseal vessels, is essential for the normal death of the chondrocytes. If the metaphysis adjacent to the physis is disrupted, the physeal cartilage widens and becomes irregular because it does not ossify normally. On the contrary, scurvy does not alter mineralization of the cartilage, and in fact, the zone of provisional calcification is very prominent in this condition. Answer C is incorrect. Explanation: A metaphyseal infarct results in disruption of the metaphyseal vascularity and focal areas of physeal cartilage persisting into the metaphysis. This is seen following radiation therapy, steroids and in Legg-Calve-Perthes disease. Therefore, C. is true. Answer D is incorrect. Explanation: Trauma to the metaphyseal spongiosa can injure the metaphyseal vessels and alter endochondral ossification. Persistence of cartilage into the metaphysis is seen following the classic metaphyseal injury in non-accidental trauma, so D. is true. Answer A is incorrect. Explanation: Similar disruption occurs after certain Salter-Harris fractures that involve the metaphysis, and is typical for the lesions due to chronic physeal stress from chronic sports injury; A. is true. Answer E is incorrect. Explanation: Vitamin D deficiency also results in failure of endochondral ossification. The tongues of physeal cartilage extending into the metaphysis result in the classic picture of metaphyseal fraying. Vitamin D is necessary for normal metaphyseal angiogenesis, and with rickets the normal apoptosis of the physeal chondrocytes does not occur; thus, E. is true. References 1. Laor T, Wall EJ, Vu LP. Physeal widening in the knee due to stress injury in child athletes. AJR Am J Roentgenol. 2006 May;186(5):1260-4. 2. Laor T, Hartman AL, Jaramillo D. Local physeal widening on MR imaging: an incidental finding suggesting prior metaphyseal insult. Pediatr Radiol. 1997 Aug;27(8):654-62. 3. Kleinman PK, Marks SC Jr, Spevak MR, Belanger PL, Richmond JM. Extension of growth- plate cartilage into the metaphysis: a sign of healing fracture in abused infants. AJR Am J Roentgenol. 1991 Apr;156(4):775-9. Pediatric Musculoskeletal Ultrasound: Cases Reviewed and Lessons Learned Jessica R. Leschied, MD 3. A single sagittal grayscale image of the volar surface of the middle finger demonstrates an injury to which structure? A. Flexor tendon B. Sagittal band C. Annular pulley D. Volar bowstring Correct Answer: C Rationale The ultrasound image depicts the normal flexor tendon crossing over the proximal interphalangeal joint with fluid deep to the tendon. Superficial to the flexor tendon is a linear area of hypoechogenicity that represents an injured A3 annular pulley. This injury is most commonly seen in competitive rock-climbers. Answer _A___ is incorrect. Explanation: The flexor tendon appears normal. Answer _B___ is incorrect. Explanation: The sagittal band, or extensor hood, is a band of ligaments that encompasses the extensor tendons on the dorsal side of the metacarpophalangeal joints. The integrity of the sagittal band prevents extensor tendon subluxation. Answer __D__ is incorrect. Explanation: This is a distractor. The volar bowstring is not an anatomic structure but an indirect sign of full thickness pulley injury. With flexion of the finger against resistance, the flexor tendon will become displaced away from the joint creating a so-called “bowstring” of the tendon. Reference 1. Fundamentals of Musculoskeletal Ultrasound, 2e (Fundamentals of Radiology) by Jon A. Jacobson MD. Chapter 5: Wrist and Hand Ultrasound. P.110-161. 4. Which of the following will distinguish a full-thickness ulnar collateral ligament tear in the elbow from a partial-thickness injury on ultrasound? A. Widening of the ulnohumeral joint with valgus stress B. The presence of ligament calcifications. C. Hypoechoic swelling and heterogeneity to the ligament fibers. D. Fluid in the elbow joint. Correct Answer: A Rationale Distinguishing between a partial and full-thickness tear of the ulnar collateral ligament can be difficult especially if there is fluid or hemorrhage in the ligament fibers due to an acute injury. Using dynamic sonographic evaluation of the ligament while applying valgus stress to the elbow can demonstrate widening of the ulnohumeral joint, asymmetric to the contralateral side, in the setting of a full-thickness tear. Answer _B_is incorrect. Explanation: The presence of ligament calcifications can be detected by plain film or ultrasound and suggests the presence of a chronic or remote ligament injury. Answer _C_ is incorrect. Explanation: Hypoechoic swelling and heterogeneity of the ligament can be see in a partial ligament tear or sprain injury. Answer _D_ is incorrect. Explanation: An elbow joint effusion is non-specific and can be seen in the setting of a number of pathologies of the elbow. Reference 1. Nazarian LN, McShane JM, Ciccotti MG, et al.: Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in asymptomatic major league baseball pitchers. Radiology. 227:149-154 2003 Sacroiliitis Jacob L. Jaremko, MD, PhD, FRCPC 5. Of these imaging features, the most specific for diagnosis of sacroiliitis is: A. periarticular fat infiltration B. bone marrow lesion (BML) C. subchondral sclerosis D. erosions Correct Answer: D Rationale Erosions, when present, were much more specific for sacroiliitis than the other listed imaging features. Answer _A___ is incorrect. Explanation: Sacral marrow fat infiltration can also occur with normal development and from mechanical changes. Answer _B___ is incorrect. Explanation: BML is the second-best answer but can also be seen from mechanical etiologies such as transitional lumbosacral junction. Answer _C___ is incorrect. Explanation: Sclerosis is highly nonspecific and can be normal. Reference 1. Jaremko et al., J Rheum 2014;41(5):963-970 6. To diagnose sacroiliitis at MRI in pediatric patients, evidence suggests gadolinium is most appropriate: A. in every case B. never C. if high intra-articular STIR signal is seen without BML D. if BML is seen without high intra-articular STIR signal Correct Answer: C Rationale Gadolinium provides minimal diagnostic benefit over a T1/STIR protocol except in selected cases with isolated high intra-articular STIR signal. Answer _A___ is incorrect. Explanation: Fluid- sensitive sequences are sufficient to detect acute & chronic lesions consistent with…sacroiliitis in children”. Answer _B___ is incorrect. Explanation: As above, there are situations in which gadolinium can clarify the diagnosis. Answer _D___ is incorrect. Explanation: BML is well visualized without gadolinium. Reference 1. Herregods et al., Skel Radiol, 2015;44(11):1637-46 2. Weiss et al., Arth Rheum, 2015;67(8):2250-6 .
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