IMAGING OF GROWTH DISTRUBANCE IN CHILDREN
Section snippets
ENCHONDRAL OSSIFICATION
The developing ends of long bones can be divided into segments based on their tissue composition and contribution to growth: cartilaginous epiphyseal unit, osseous metaphysis, and fibrous perichondrium.
The epiphyseal unit includes the epiphysis and the physis (or growth plate) and contributes most to the longitudinal growth of the bone. The physis is a specialized part of the epiphysis divided into zones based on histology and function (Fig. 1). The region of the physis adjacent to the
VASCULAR ANATOMY
The epiphyseal artery supplies the epiphysis and the SOC. Its branches course through small canals to the germinal and upper proliferative zones of the physis. Early in life, some of these canals extend from the epiphysis into the metaphysis allowing direct extension of metaphyseal pathology across the physis (Fig. 2). As the SOC enlarges, however, the vascular canals converge and the transphyseal vessels atrophy by the first year of life.
The metaphysis has a rich blood supply from the nutrient
MECHANISMS OF GROWTH DISTURBANCE
The most widely described type of growth disturbance is physeal arrest with bone bridge formation across the physis. Additionally, physeal dysfunction without bridge formation occurs with resultant physeal irregularity or widening. Epiphyseal growth disruption generally leads to a small SOC with abnormal contour or fragmentation. Disturbance of metaphyseal growth disrupts remodeling with loss of the normal funnel shape. Membranous growth impairment resulting from injury to the perichondrial
PHYSEAL FRACTURES AND GROWTH ARREST
Approximately 15% of all pediatric fractures involve the physis12 and 15% of those lead to growth arrest requiring surgical management.19 The phalanges and the distal radius are the most common sites of physeal fracture but infrequently result in growth arrest. Conversely, the distal femur and proximal tibia are infrequent sites of physeal fracture (1.4% and 0.8%, respectively) with disproportionately high incidences of post-traumatic bridge formation (35% and 16%, respectively).20 The most
IMAGING OF GROWTH ARREST
The goal of imaging patients with growth disturbance is accurate demonstration of the physeal cartilaginous pathology and depiction of the size and location of bone bridges relative to the remainder of the physis to guide surgical management. Bridge size determines the surgical procedure. Bridges comprising less than 50% of the physeal area may be resected with good prognosis.18 Larger bridges may require ipsilateral epiphysiodesis to prevent angular deformity, contralateral epiphysiodesis to
Proximal Femur
Growth disturbance of the proximal femur is most commonly ischemic secondary to hyperabduction therapy for DDH, Legg-Calvé-Perthes disease, and rapidly developing effusions caused by hip infection. The proximal femoral physis is particularly vulnerable because the epiphyseal artery is intra-articular. Attenuation of the artery by abduction or increased intra-articular pressure leads to ischemia of the epiphysis and germinal and proliferative zones of the physis. The proximal femur has a unique
SUMMARY
Growth disturbance of the long bones in children is frequently post-traumatic but also occurs because of physeal, epiphyseal, or metaphyseal ischemia. The imaging features of growth arrest depend more on the anatomic site involved than on the cause. The physes of the distal tibia and femur and proximal tibia are disproportionately at risk because of their complex geometry. The central undulation in the distal femur and the bump in the anteromedial physis (Kump's bump) in the distal tibia are
References (23)
The growth plate
Orthop Clin North Am
(1984)Growth plate physiology and pathology
Orthop Clin North Am
(1990)- et al.
Growth cartilage: Normal appearance, variants and abnormalities
Magn Reson Imaging Clin North Am
(1998) - et al.
Normal maturing distal tibia and fibula: Changes with age at MR imaging
Radiology
(1995) - Ecklund K, Jaramillo D: Patterns of physeal arrest: MR imaging experience in 111 children. In Program of the Society...
- et al.
Chondro-osseous growth abnormalities after meningococcemia: A clinical and histopathological study
J Bone Joint Surg Am
(1989) - et al.
Growth plate of the normal knee: Evaluation with MR imaging
Radiology
(1992) - et al.
Growth disturbance lines after injury of the distal tibial physis: Their significance in prognosis
J Bone Joint Surg Br
(1988) - et al.
Cartilaginous path of physeal fracture-separations: Evaluation with MR imaging—an experimental study with histologic correlation in rabbits
Radiology
(2000) - et al.
Indirect trauma to the growth plate: Results of MR imaging after epiphyseal and metaphyseal injury in rabbits
Radiology
(1993)
Local physeal widening on MR imaging: An incidental finding suggesting prior metaphyseal insult
Pediatr Radiol
Cited by (68)
Gymnast's wrist in a 12-year-old female with MRI correlation
2019, Radiology Case ReportsCitation Excerpt :Unfortunately, if not identified and treated, there is risk of progression. In the more severe setting, trauma can result in communication between epiphyseal and metaphyseal vessels, with resultant development of a bony bridge across the physis leading to asymmetric growth of the physis or even premature growth arrest [20]. As such, it is essential for the radiologist to be aware of such entities so that the provider may take action before injuries become irreversible.
Musculoskeletal Traumatic Injuries in Children: Characteristic Imaging Findings and Mimickers
2017, Radiologic Clinics of North AmericaCitation Excerpt :Typical locations for stress fractures in young athletes include the tibia, fibula, metatarsals, and femur.50 Premature physeal closure in children is most often posttraumatic.13,51 The morbidity associated with premature physeal closure and bony bridge formation is determined by the age of the patient, bone affected, and location of the bony bridge.
MR Imaging of the Pediatric Foot and Ankle: What Does Normal Look Like?
2017, Magnetic Resonance Imaging Clinics of North AmericaDiagnostic Imaging: Pediatrics
2017, Diagnostic Imaging: PediatricsAn anatomic and 3D study of the development of the proximal humeral physis
2022, Surgical and Radiologic AnatomyImaging Review of Normal and Abnormal Skeletal Maturation
2022, Radiographics
Address reprint requests to Kirsten Ecklund, MD, Department of Radiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115. e-mail: [email protected]