IMAGING OF GROWTH DISTRUBANCE IN CHILDREN

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Disturbance of skeletal growth occurs often in children and results in considerable lifelong disability. When acquired, it is most frequently post-traumatic but may also be caused by other insults, such as infection, ischemia, tumoral lesions, and radiation.15 The complications of growth disturbance (leg length discrepancy, angular deformity, and altered joint mechanics) cause significant morbidity. MR imaging, with its ability to depict the cartilaginous structures of developing bones, has become the modality of choice for evaluating children with growth disorders and directing surgical management. An understanding of normal enchondral ossification and the anatomy of the ends of growing bones is essential for appreciation of the MR imaging findings in such patients.

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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

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    Address reprint requests to Kirsten Ecklund, MD, Department of Radiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115. e-mail: [email protected]

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