The periphysis and its effect on the metaphysis: I. Definition and normal radiographic pattern

The zone of Ranvier and the ring of LaCroix, together with the membranous bone bark they produce, are termed the periphysis in order to emphasize their normal effect (the metaphyseal collar) on the metaphysis of the infant and young child. In the first 7 years of life, the normal collar at the wrist is 1-3 mm wide. The step-off between the metaphyseal collar and the curvilinear metaphysis, at the margin of the periphysis, should not be mistaken for abuse fracture. The periphyseal bone bark may be radiologically visible at the edge of the physis at the distal ulna in 9% of infants and should not be mistaken for fracture or rickets.

MR demonstrates cartilaginous megaepiphyses of the hips in Kniest dysplasia of the young child

MR imaging of a 2-year-old girl with Kniest dysplasia revealed abnormally large cartilaginous femoral heads. Although ossification of the femoral head is delayed in Kniest dysplasia, it is nonetheless also a megaepiphyseal growth center with respect to the cartilage model.

Imaging of the skeleton and soft tissue in children

Normal metaphyses in infants contain a step-off not to be confused with child abuse. Extension of physeal lucency into the metaphyses can be a sign of healing child-abuse fracture of experimental physeal fracture, as well as deferoxamine overdose. Sonography can reveal costochondral dislocation, the pattern of healing fracture callus, the patellar tendon in jumper's knee, synovium of rheumatoid arthritis, sequestrum in advanced osteomyelitis, the unossified dislocated patella, and, even after 2 years of age, the dislocated femoral head. Further developments concern bone scanning, MR imaging, CT, and plain films of specific trauma, tumor, and infectious, metabolic, and orthopaedic conditions. Ultrasound has been proven useful for radiologist removal of soft tissue foreign bodies, whereas CT can be helpful for osteoid osteoma nidus removal under imaging control.

Prenatal diagnosis of recurrent Larsen syndrome: further definition of a lethal variant

Larsen syndrome is characterized by multiple congenital joint dislocations and flattened facies. Some cases have been familial, with both autosomal dominant and recessive patterns of inheritance. Reports of a form of Larsen syndrome, lethal in the neonatal period, are reviewed. We present a family in which recurrence of the syndrome was diagnosed prenatally, but a lethal outcome again resulted despite preparation for anticipated perinatal complications. Because of the wide clinical variation and the lack of a known metabolic defect, delineation between the various forms of Larsen syndrome is difficult. While the lethal variant appears to be a combination of the Larsen phenotype and pulmonary hypoplasia, other features noted in the lethal cases, such as abnormal palmar creases and laryngotracheomalacia, are also seen in patients with Larsen syndrome who survive.

Radio-ulnar synostosis in Williams syndrome. A frequently associated anomaly

Limitation of supination and pronation of the forearm has been occasionally described in individuals with Williams syndrome. It was found in 26% of 23 subjects examined, and was associated with a spectrum of severity of radio-ulnar synostosis on radiography. The occurrence of this functional motor impairment in a substantial subset of persons with Williams syndrome is relevant, because its evaluation is important in habilitation planning.

Spectrum and natural history of congenital hyperparathyroidism secondary to maternal hypocalcemia

Fourteen cases of congenital hyperparathyroidism secondary to maternal hypocalcemia have been reported. We report two additional cases that highlight the wide spectrum of the disease. We extensively studied the parathyroid function of these infants to test the hypothesis that the biochemical hyperparathyroidism found in these infants would be transient in nature, since the presumed etiology (maternal and subsequent fetal hypocalcemia) should disappear soon after birth with establishment of enteral feedings. Infant 1 was born to a mother with idiopathic hypoparathyroidism with poor compliance to therapy and documented hypocalcemia in pregnancy. Severe congenital demineralization and intrauterine fractures with clinical and radiologic bowing of the long bones were obvious. Bone mineral content and bone mineral content/bone width ratio, measured by photon absorptiometry, were both markedly below normal. Infant 2 was born to a mother with postsurgical hypoparathyroidism with excellent compliance. The mother was normocalcemic. The infant was clinically and radiologically asymptomatic. The bone mineral content was just at the lower limit of normal, but bone mineral content/bone width ratio was below the normal limits. Biochemical features include elevation of cord serum parathyroid hormone (1-84, radioimmunoassay) in both cases, coexisting with serum calcium, phosphorus concentrations within normal limits. Serum parathyroid hormone fell to within normal ranges by 9 days of age in both infants. With no treatment, bone mineral content at 1 month of age was normal in both infants.

Ultrasound diagnosis of Hirschsprung disease in the infant with distended abdomen

It is possible to diagnose Hirschsprung disease by real-time ultrasound, as demonstrated by the case of an apparently asymptomatic 1-month-old baby boy who was found to have a distended abdomen at well-baby check-up.

Normal thymus in infancy: sonographic characteristics

A prospective sonographic study of the normal thymus in 56 infants was performed to determine the shape, extent, and echogenicity of normal thymic tissue. The thymus had either a triangular or teardrop shape on longitudinal scans and a trapezoidal or bilobate shape on transverse scans. Typically, the thymus was located anterior to the great vessels and extended down to the upper portion of the heart (in one infant, to the diaphragm). It extended up into the lower cervical area in five infants. The great vessels--including the superior vena cava, aorta, and the pulmonary artery--were well imaged through the thymus. In six infants the thymus encircled the left innominate vein. The echogenicity of the thymus was homogeneous, similar to that of the liver and spleen. The intensity of thymic echogenicity was less than that of the liver, spleen, and thyroid gland. This study demonstrates that the thymus has a characteristic sonographic appearance and can be easily identified.

Minimal vitamin D and high calcium and phosphorus needs of preterm infants receiving parenteral nutrition

Preterm infants (birth weight, 1,089 +/- 91 g; gestational age, 28.9 +/- 0.7 weeks; mean +/- SEM) with mixed medical and surgical indications for parenteral nutrition (PN) were observed to determine the adequacy of infusates with fixed, low-dose vitamin D (25 IU/dl) and two combinations of calcium and phosphorus. The duration of low-dose vitamin D PN ranged from 5 to 52 days, with a median of 27 days. Twelve infants were randomly assigned to low (standard) Ca and P doses (5 mM each; 20 mg/dl of Ca and 15.5 mg/dl of P) and 13 high Ca and P doses (15 mM each; 60 mg/dl of Ca and 46.5 mg/dl of P). The maximum daily vitamin D intake was similar for both groups (31 +/- 1.3 versus 33 +/- 1.2 IU/kg). Vitamin D status in either group, as indicated by serum 25-hydroxyvitamin D (25-OHD) concentrations, was normal. There was no significant difference in observed changes of serial measurements of serum calcium, magnesium, phosphorus, alkaline phosphatase, creatinine (Cr), 25-OHD, and vitamin D-binding protein concentrations or urinary Ca:Cr and Mg:Cr ratios. In the low-dose Ca and P group, the serum P level was consistently less than 4 mg/dl in five infants, serum 1,25-dihydroxyvitamin D concentrations were higher, and tubular reabsorption of phosphorus was consistently greater than 95% and significantly higher than in the high-dose Ca and P groups. Severe bone demineralization apparent on X-ray occurred in two infants, with a fractured distal left ulna in one of the two infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Prominent transverse (Bowdler) bone spurs as a diagnostic clue in a case of neonatal hypophosphatasia without metaphyseal irregularity

Transverse midshaft spurs allowed a diagnosis of hypophosphatasia in a newborn infant without metaphyseal irregularity.

Sequential bone mineral content in small preterm infants with and without fractures and rickets

Seventy-four infants with birth weights 1009 +/- 28 grams and gestational age 28.6 +/- 0.3 weeks (M +/- SEM) were studied prospectively to test the hypotheses that bone mineral content (BMC) measured by photon absorptiometry, would be: (1) lower in very low birth weight (VLBW) infants with radiographic evidence of fractures and/or rickets (F/R), and (2) will continue to be lower over the first year when compared to VLBW infants without F/R. BMC and bone width (BW) of the distal one-third of left radius and ulna were measured at 5 weeks (n = 8), 14 weeks (n = 61), 26 weeks (n = 58), 40 weeks (n = 59), and 1 year (n = 52). Standardized radiographs of both forearms, and weight, length, and head circumference were also determined at each study age. Investigators and technicians involved in the photon absorptiometry measurements were unaware of the radiographic findings and vice versa. Twenty-three of 74 infants were found to have F/R. BMC of studied infants remained markedly below our previously determined range of "intrauterine bone mineralization," even at 26 weeks after birth. There was no significant difference in BMC or BW between infants with and without F/R, either at the time of confirmation of F/R or during early follow-up; however, BMC was lower at greater than or equal to 6 months and BW was lower at greater than or equal to 9 months in infants with F/R. We suggest that the extremely low BMC measurements in early infancy predispose all VLBW infants to fractures and rickets.

Cerebro-costo-mandibular syndrome with stippled epiphysis and cystic fibrosis

We present a patient with cerebro-costo-mandibular syndrome who also had cystic fibrosis, hydrocephalus, and multiple ossification centers of the calcaneus.

Vitamin D requirement in infants receiving parenteral nutrition

The adequacy of low dose vitamin D (25 IU/dl) parenteral nutrition (PN) solution was studied in 18 infants. All infants had surgical indications for PN. The birth weights were 2810 +/- 135 g and gestational ages 37.4 +/- 0.5 wk (mean +/- SEM). Duration of study ranged from 5 to 175 days. Thirteen infants were studied for up to 6 weeks and five infants for 71 to 175 days. Results showed that studied infants maintained growth along normal percentiles for weight, length, and head circumference. Vitamin D status as indicated by serum 25 hydroxyvitamin D (25 OHD) rose from 15 +/- 1.9 ng/ml to 26 +/- 2.8 ng/ml, mean +/- SEM (p less than 0.001) after 9 days, and remained normal up to 6 months. Five infants with biochemical liver dysfunction also had normal serum 25 OHD concentrations, indicating the hepatic 25 hydroxylation process was not severely impaired. Serum total and ionized calcium, phosphorus, and vitamin D-binding protein concentrations were normal. Serum magnesium was mildly elevated in five infants (2.6 to 3 mg/dl) on one occasion and resolved spontaneously. Serum alkaline phosphatase (AP) concentrations rose above baseline values in 12 of 17 infants, but remained within normal range (less than 400 IU/liter at 30 degrees C). Another infant with markedly elevated AP values died from liver dysfunction. Radiographs of the forearms were normal except for marked demineralization in one infant in spite of normal 25 OHD concentrations. We conclude that 25 IU vitamin D/dl of nutrient infusate is adequate to maintain normal vitamin D status, as indicated by normal serum 25 OHD concentrations in infants receiving PN for as long as 6 months.

Parenteral nutrition for infants: effect of high versus low calcium and phosphorus content

Calcium (Ca) and phosphorus (P) homeostasis were determined in 18 infants (birth weight, 2,810 +/- 135 g; gestational age, 37.4 +/- 0.5 weeks; mean +/- SEM) who received high or low Ca and P content (Ca, P) parenteral nutrition (PN) with a fixed, low dose of vitamin D (25 IU/dl). Nine infants were randomized into low (standard) Ca, P (20 mg Ca and 15.5 mg P/dl) and nine into high Ca, P (60-80 mg Ca and 46.5-62 mg P/dl) PN, and then were studied for up to 6 weeks. The high Ca, P group had stable serum 1,25 dihydroxyvitamin D [1,25(OH)2D], which consistently remained within the normal range (less than 116 pg/ml). Tubular reabsorption of phosphorus (TRP) also was stable and remained consistently less than 90%. The low Ca, P group had elevated and higher 1,25(OH)2D (p = 0.03) than the high Ca, P group. The mean serum 1,25(OH)2D concentration rose from 32 to 112, 115, and 133 pg/ml over a period of 6 weeks. TRP also was higher (p = 0.02) and remained consistently greater than 90%. There were no significant differences between groups in serum parathyroid hormone, calcitonin, Ca, Mg, P, alkaline phosphatase, vitamin D binding protein, and 25 hydroxyvitamin D concentrations; urine Ca/creatinine and Mg/creatinine ratios, and fractional excretion of sodium (Na). Thus, a "high" Ca (60 mg/dl) and P (46.5 mg/dl) content in PN solutions can result in stable serum 1,25(OH)2D and TRP, presumably reflecting minimal stress to Ca and P homeostatic mechanisms without further increase in urinary Ca excretion.

Sonography of neck masses in children

The sonograms and medical records of 49 patients were reviewed to determine if there is a characteristic sonographic appearance for certain neck masses. Neck masses included: inflammatory masses (12), noninflammatory masses (23), and thyroid masses (14). Four entities including thyroglossal duct cyst, fibromatosis colli, cystic hygroma, and multiple lymphadenopathy showed characteristic sonographic appearance. Thyroglossal duct cysts were seen as midline or slightly off midline cystic masses. A sinus tract extending superiorly was nicely demonstrated in one patient. The mass in fibromatosis colli (neonatal torticollis) appeared as a well defined mass clearly within the sternocleidomastoid muscle, uniformly echogenic, but less echogenic than the normal surrounding muscle, without good through-transmission. A cystic or primarily cystic mass with linear septations was the characteristic finding of the cystic hygroma. Multiple lymphadenopathy demonstrated multiple discrete, oval, relatively hypoechoic masses along the cervical lymphatic chain. The sonographic appearance of inflammatory masses was variable, being either inhomogeneously echogenic or of mixed echogenicity. Hemangiomas were either echogenic with cystic vascular spaces or linear septations or relatively homogeneously echogenic. Intrinsic thyroid masses could be distinguished from extrinsic masses in most cases. The demonstration of calcification in a mass was useful in narrowing the differential diagnosis. Although it is not a specific finding, the presence of calcification highly suggests a neoplastic lesion, particularly neuroblastoma or teratoma. Not only can the location, extent, and internal characteristics of a mass be determined, but in certain entities, the sonographic appearance is characteristic and an accurate diagnosis can be made.

The stylohyoid ligament in Hurler syndrome and related conditions: comparison with normal children

The stylohyoid ligament is seen on lateral radiographs of the neck to be normally calcified to some extent in approximately 25% of all children between ages 1 1/2 and 15. When it appears, the ossification pattern is a relatively thin configuration in 90% of children. In 8 out of 9 children with Hurler syndrome, the stylohyoid was calcified, and was thicker than in normal children. This finding illustrates the nature of the stylohyoid ligament as a bone analogue, and its participation in the skeletal deformation pattern of dysostosis multiplex.

Sonography of brain tumors in infants

Cranial sonograms of six children with brain tumors (one newborn, four infants, and one 4-year-old child) are presented. In four, sonography showed a large tumor mass and displacement of adjacent structures. In two, the tumors were demonstrated as areas of abnormal brain parenchymal echogenicity without obvious mass effect. Two of the tumors were diffusely echogenic, one was primarily cystic, and three were of mixed echogenicity. Areas of cystic degeneration and calcification within the tumors were well demonstrated. Correlation was made with cranial computed tomography (CT) in all patients; in each case sonography accurately demonstrated the location and extent of the tumor. Since sonography is used as a screening procedure in infants with a large head or an abnormal neurologic examination, sonography may be the first examination to demonstrate the tumor mass. However, since the sonographic features are not specific for neoplasms, further clarification of the process by CT should be recommended.

Pharyngonasal reflux: spectrum and significance in early childhood

The radiographic and clinical findings of 57 infants and children demonstrating pharyngonasal reflux during barium swallow were reviewed. Pharyngonasal reflux is most frequent in the first 3 months of life and may occur in children with apneic episodes. Clinical symptoms in this group of children generally clear, even when reflux is severe. Pharyngonasal reflux may be associated with prematurity, neuromuscular disease, velopharyngeal incoordination, and other conditions but is usually of no consequence in very young infants.

Danger of loss of reduction of supracondylar elbow fracture during radiography

All too often, the labors of manipulation and anatomical reduction of a supracondylar humeral fracture of the elbow requiring, perhaps, an hour or two, are noticed to be lost once the patients' follow-up radiographs are seen. It is our feeling that the reduction is lost when the forearm is externally rotated for the lateral view of the elbow. To prevent this, we recommend placing the X-ray cassette in the axilla to obtain the true lateral view, thus preventing the unsupervised rotation of the fracture.

Transient loss of femoral head Tc-99m diphosphonate uptake with prolonged maintenance of femoral head architecture

Nine pediatric patients presented with synovitis and suspected Legg-Perthes disease, hemarthrosis, acute slipped capital femoral epiphysis, prolonged traumatic hip dislocation, or transcervical femoral fracture. All had hip scintigraphs that showed loss of Tc-99m diphosphonate uptake in the affected femoral head. Radiographic changes associated with aseptic necrosis failed to appear during the initial follow-up period of three to 14 months. Repeat scintigraphy showed complete revascularization in six cases and partial revascularization in two. Reambulation at 1.5 to eight months after presentation was accomplished without recurrence of pain in seven cases, without development of x-ray changes in 5 cases. Three children developed x-ray changes associated with avascular necrosis after reambulation, while one child had minimal x-ray changes. Some children with loss of uptake in the femoral head do not develop x-ray changes associated with aseptic necrosis.