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Nguyen JC, Caine D. The Immature Pediatric Appendicular Skeleton. Semin Musculoskelet Radiol 2024; 28:361-374. [PMID: 39074720 DOI: 10.1055/s-0044-1786151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Growth and maturation occur in a predictable pattern throughout the body and within each individual bone. In the appendicular skeleton, endochondral ossification predominates in long bones and growth plates. The ends of these long bones are sites of relative weakness in the immature skeleton and prone to injury from acute insult and overuse. We present the normal histoanatomy and physiology of the growth plate complex, highlighting the unique contribution of each component and shared similarities between primary and secondary complexes. Components of the growth plate complex include the physis proper, subjacent vascularity within the growth cartilage, and the ossification front. The second section describes imaging considerations and features of normal and abnormal growth. Finally, we review the Salter-Harris classification for acute fractures and offer examples of characteristic overuse injury patterns involving the epiphyseal (proximal humerus and distal radius), apophyseal (medial epicondyle and tibial tubercle), and secondary growth plate complexes (medial femoral condyle and capitellar osteochondritis dissecans). This article provides a foundation and basic framework to better understand and anticipate potential complications and growth disturbances and to ensure optimal follow-up and early intervention when treatment can be less invasive.
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Affiliation(s)
- Jie C Nguyen
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dennis Caine
- Division of Education, Health and Behavior Studies, Kinesiology and Public Health Education, University of North Dakota, Grand Forks, North Dakota
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Whole body magnetic resonance imaging in healthy children and adolescents.Bone marrow appearances of the appendicular skeleton. Eur J Radiol 2022; 153:110365. [DOI: 10.1016/j.ejrad.2022.110365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/28/2022] [Accepted: 05/14/2022] [Indexed: 11/22/2022]
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3
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Zadig P, von Brandis E, d’Angelo P, de Horatio LT, Ording-Müller LS, Rosendahl K, Avenarius D. Whole-body MRI in children aged 6-18 years. Reliability of identifying and grading high signal intensity changes within bone marrow. Pediatr Radiol 2022; 52:1272-1282. [PMID: 35445816 PMCID: PMC9192437 DOI: 10.1007/s00247-022-05312-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/08/2021] [Accepted: 02/03/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Whole-body magnetic resonance imaging (MRI) is increasingly being used in children, however, to date there are no studies addressing the reliability of the findings. OBJECTIVE To examine intra- and interobserver reliability of a scoring system for assessment of high signal areas within the bone marrow, as visualized on T2-weighted, fat-saturated images. MATERIALS AND METHODS Ninety-six whole-body MRIs (1.5 T) in 78 healthy volunteers (mean age: 11.5 years) and 18 children with chronic nonbacterial osteomyelitis (mean age: 12.4 years) were included. Coronal water-only Dixon T2-weighted images were used to score the left lower extremity/pelvis for high signal intensity areas, intensity (0-2 scale), extension (0-4 scale) and shape and contour in a blinded fashion by two pairs of radiologists. RESULTS For the pelvis, grading of bone marrow signal showed moderate to good intra- and interobserver agreement with kappa values of 0.51-0.94 and 0.41-0.87, respectively. Corresponding figures for the femur were 0.61-0.68 within and 0.32-0.61 between observers, and for the tibia 0.60-0.72 and 0.51-0.73. Agreement for assessing extension was moderate to good both within and between observers for the pelvis (k = 0.52-0.85 and 0.35-0.80), for the femur (0.52-0.67 and 0.51-0.60) and for the tibia (k = 0.59-0.69 and 0.47-0.63) except for the femur metaphysis/diaphysis, with interobserver kappa values of 0.29-0.30. Scoring of shape was moderate to good within observers, but in general poorer between observers, with kappa values of 0.40-0.73 and 0.18-0.69, respectively. For contour, the corresponding figures were 0.35-0.62 and 0.09-0.54, respectively. CONCLUSION MRI grading of intensity and extension of high signal intensity areas within the bone marrow of pelvis and lower limb performs well and thus can be used interchangeably by different observers, while assessment of shape and contour is reliable for the same observer but is less reliable between observers. This should be considered when performing clinical trials.
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Affiliation(s)
- Pia Zadig
- Department of Radiology, University Hospital of North-Norway, Tromsø, Norway. .,Department of Clinical Medicine, Uit, The Arctic University of Norway, Tromsø, Norway.
| | - Elisabeth von Brandis
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Paola d’Angelo
- Department of Pediatric Radiology, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Laura Tanturri de Horatio
- Department of Clinical Medicine, Uit, The Arctic University of Norway, Tromsø, Norway ,Department of Pediatric Radiology, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Karen Rosendahl
- Department of Radiology, University Hospital of North-Norway, Tromsø, Norway ,Department of Clinical Medicine, Uit, The Arctic University of Norway, Tromsø, Norway
| | - Derk Avenarius
- Department of Radiology, University Hospital of North-Norway, Tromsø, Norway ,Department of Clinical Medicine, Uit, The Arctic University of Norway, Tromsø, Norway
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Vanmarsnille T, Laloo F, Herregods N, Jaremko JL, Verstraete KL, Jans L. Pediatric Imaging of the Elbow: A Pictorial Review. Semin Musculoskelet Radiol 2021; 25:558-565. [PMID: 34706385 DOI: 10.1055/s-0041-1735468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The elbow is a complex joint, subject to a wide range of traumatic, inflammatory, metabolic and neoplastic insults. The pediatric elbow has several diagnostic pitfalls due to the normal developmental changes in children. Knowledge of these normal variants is essential for both diagnosis and management of their elbow injuries. Radiography remains the first imaging modality of choice. Magnetic resonance imaging is excellent in evaluating lesions within the bone and soft tissues. In this pictorial essay, we provide insights into pediatric elbow imaging, show a range of entities specific to the pediatric elbow, and discuss diagnostic pitfalls that result from normal elbow growth in children.
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Affiliation(s)
- Tim Vanmarsnille
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Frederiek Laloo
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Nele Herregods
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Jacob L Jaremko
- Department of Radiology & Diagnostic Imaging, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Koenraad L Verstraete
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Lennart Jans
- Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
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Walter WR, Goldman LH, Rosenberg ZS. Pitfalls in MRI of the Developing Pediatric Ankle. Radiographics 2020; 41:210-223. [PMID: 33216674 DOI: 10.1148/rg.2021200088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Normal skeletal development in the pediatric ankle is dynamic and often produces variable imaging appearances that are subject to misinterpretation. Radiologists must understand the underlying developmental phenomena, such as endochondral and membranous ossification and physeal fusion, and be familiar with their common and uncommon imaging manifestations unique to the pediatric ankle. This is especially true as the use of MRI in the evaluation of musculoskeletal trauma expands among younger populations. The authors focus on MRI evaluation of the skeletally maturing pediatric ankle and present pearls for accurately distinguishing normal findings and imaging pitfalls from true pathologic findings. The normal but often variable imaging findings of preossification, secondary ossification, and multiple ossification centers, as well as the range of bone marrow signal intensities that can be visualized within ossification centers, are described, along with tips to help differentiate these from true pathologic findings such as contusion, fracture, or tumor. The authors also review dynamic periosteal and physeal contributions to bone growth to highlight helpful distinguishing features and avoid misdiagnosis of common subperiosteal and periphyseal abnormalities. For example, the normal trilaminar appearance of the immature cortex and periosteum should not be mistaken for periosteal reaction, traumatic stripping, or subperiosteal hematoma. In addition, the physis can have several confusing but normal appearances, including normal physeal undulations (eg, Kump bump) or focal periphyseal edema, which should not be mistaken for pathologic findings such as physeal fracture, infection, or bar. ©RSNA, 2020.
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Affiliation(s)
- William R Walter
- From the Department of Radiology, NYU Langone Health, 301 E 17th St, 6th Floor, New York, NY 10003
| | - Lauren H Goldman
- From the Department of Radiology, NYU Langone Health, 301 E 17th St, 6th Floor, New York, NY 10003
| | - Zehava S Rosenberg
- From the Department of Radiology, NYU Langone Health, 301 E 17th St, 6th Floor, New York, NY 10003
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Patel MD, Brian J, Chauvin NA. Pearls and Pitfalls in Imaging Bone Marrow in Pediatric Patients. Semin Ultrasound CT MR 2020; 41:472-487. [DOI: 10.1053/j.sult.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Normal development imaging pitfalls and injuries in the pediatric shoulder. Pediatr Radiol 2019; 49:1617-1628. [PMID: 31686168 DOI: 10.1007/s00247-019-04512-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/27/2019] [Accepted: 08/12/2019] [Indexed: 10/25/2022]
Abstract
The skeletal maturation of the shoulder has been well documented on radiographic and cadaveric studies. Recent increased use of MRI has provided increased understanding of the soft-tissue and osseous changes that occur during development. Thus recognizing normal maturation, imaging manifestations and pitfalls is crucial when evaluating the pediatric shoulder joint. At birth, the humeral diaphysis, midportion of the clavicle, and the body of the scapula are ossified, while the remainder of the bones of the shoulder are composed of non-ossified cartilaginous precursors. During growth, cartilaginous apophyses and epiphyses of the shoulder develop numerous secondary ossification centers, which fuse with the primary ossification centers to form the complete bony components of the shoulder. Additionally changes in the morphology of the growth plates as well as marrow signal occur in an organized manner. This paper affords the reader with an understanding of the normal development of three major components of skeletal maturation in the shoulder: ossification centers, growth plates and marrow signal. These topics are further subdivided into the glenoid, proximal humerus and acromioclavicular joint. We also provide a focus on distinguishing normal anatomy from imaging pitfalls related to skeletal maturation.
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Nguyen JC, Sheehan SE, Davis KW, Gill KG. Sports and the Growing Musculoskeletal System: Sports Imaging Series. Radiology 2017. [DOI: 10.1148/radiol.2017161175] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jie C. Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| | - Scott E. Sheehan
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| | - Kirkland W. Davis
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| | - Kara G. Gill
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
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Zember JS, Rosenberg ZS, Kwong S, Kothary SP, Bedoya MA. Normal Skeletal Maturation and Imaging Pitfalls in the Pediatric Shoulder. Radiographics 2015; 35:1108-22. [DOI: 10.1148/rg.2015140254] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Narayanan S, Shailam R, Grottkau BE, Nimkin K. Fishtail deformity--a delayed complication of distal humeral fractures in children. Pediatr Radiol 2015; 45:814-9. [PMID: 25527301 DOI: 10.1007/s00247-014-3249-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 10/16/2014] [Accepted: 11/19/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Concavity in the central portion of the distal humerus is referred to as fishtail deformity. This entity is a rare complication of distal humeral fractures in children. OBJECTIVE The purpose of this study is to describe imaging features of post-traumatic fishtail deformity and discuss the pathophysiology. MATERIALS AND METHODS We conducted a retrospective analysis of seven cases of fishtail deformity after distal humeral fractures. RESULTS Seven children ages 7-14 years (five boys, two girls) presented with elbow pain and history of distal humeral fracture. Four of the seven children had limited range of motion. Five children had prior grade 3 supracondylar fracture treated with closed reduction and percutaneous pinning. One child had a medial condylar fracture and another had a lateral condylar fracture; both had been treated with conservative casting. All children had radiographs, five had CT and three had MRI. All children had a concave central defect in the distal humerus. Other imaging features included joint space narrowing with osteophytes and subchondral cystic changes in four children, synovitis in one, hypertrophy or subluxation of the radial head in three and proximal migration of the ulna in two. CONCLUSION Fishtail deformity of the distal humerus is a rare complication of distal humeral fractures in children. This entity is infrequently reported in the radiology literature. Awareness of the classic imaging features can result in earlier diagnosis and appropriate treatment.
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Affiliation(s)
- Srikala Narayanan
- Department of Radiology, Division of Pediatric Imaging, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
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Kothary S, Rosenberg ZS, Poncinelli LL, Kwong S. Skeletal development of the glenoid and glenoid-coracoid interface in the pediatric population: MRI features. Skeletal Radiol 2014; 43:1281-8. [PMID: 24986651 DOI: 10.1007/s00256-014-1936-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/27/2014] [Accepted: 06/01/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the MRI appearance of normal skeletal development of the glenoid and glenoid-coracoid interface in the pediatric population. To the best of our knowledge, this has not yet been studied in detail in the literature. MATERIALS AND METHODS An IRB-approved, HIPAA-compliant retrospective review of 105 consecutive shoulder MRI studies in children, ages 2 months to 18 years was performed. The morphology, MR signal, and development of the following were assessed: (1) scapular-coracoid bipolar growth plate, (2) glenoid and glenoid-coracoid interface secondary ossification centers, (3) glenoid advancing osseous surface. RESULTS The glenoid and glenoid-coracoid interface were identified in infancy as a contiguous, cartilaginous mass. A subcoracoid secondary ossification center in the superior glenoid was identified and fused in all by age 12 and 16, respectively. In ten studies, additional secondary ossification centers were identified in the inferior two-thirds of the glenoid. The initial concavity of the glenoid osseous surface gradually transformed to convexity, matching the convex glenoid articular surface. The glenoid growth plate fused by 16 years of age. Our study, based on MRI, demonstrated a similar pattern of development of the glenoid and glenoid coracoid interface to previously reported anatomic and radiographic studies, except for an earlier development and fusion of the secondary ossification centers of the inferior glenoid. CONCLUSIONS The pattern of skeletal development of the glenoid and glenoid-coracoid interface follows a chronological order, which can serve as a guideline when interpreting MRI studies in children.
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Affiliation(s)
- Shefali Kothary
- Department of Radiology, Mount Sinai Beth Israel, First Avenue at 16th Street, New York, NY, 10003, USA,
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Jaimes C, Berman JI, Delgado J, Ho-Fung V, Jaramillo D. Diffusion-tensor imaging of the growing ends of long bones: pilot demonstration of columnar structure in the physes and metaphyses of the knee. Radiology 2014; 273:491-501. [PMID: 25102295 DOI: 10.1148/radiol.14132136] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the feasibility of using in vivo diffusion-tensor imaging and tractography of the physis to examine changes related to rate of growth, location, and age. MATERIALS AND METHODS This retrospective study was institutional review board approved and HIPAA compliant and the requirement for informed consent was waived. Diffusion-tensor imaging of the knee was performed at 3.0 T in 31 subjects (nine boys and 22 girls) with a median age of 13.6 years. The mean ages of boys and girls were 14.7 years (range, 12.0-18.3 years) and 13.2 years (range, 7.0-18.6 years), respectively. Regions of interest were placed in the physis of the tibia and femur, and in the epiphyseal and articular cartilage of these bones. Tractography was performed by using a fractional anisotropic threshold of 0.15 and an angle threshold of 40°. The tractographic patterns were qualitatively evaluated and changes related to age were described. The tract-based apparent diffusion coefficient, fractional anistropy, tensor eigenvalues, and tract length were measured. Diffusion parameters were compared between the center and periphery of the physis, and between the distal femur and proximal tibia. RESULTS Tractography resulted in parallel tracts in the physis and the adjacent metaphysis. Tractographic pattern changed with age, with individuals approaching physeal closure having shorter tracts in a random arrangement. Patterns of tractography varied with age in the femur (P < .001) and tibia (P < .001). Femoral tracts (median length, 6.5 mm) were longer than tibial tracts (median length, 4.3 mm) (P < .001). Tracts in the periphery of the physes were longer than those in the center (femur, P = .005; tibia, P = .004). In the physis of the femur and tibia, a significant age-related decrease was observed in apparent diffusion coefficient (P < .001 for both), axial diffusion (femur, P = .001; tibia, P < .001), and transverse diffusion [P < .001 for both]), and an age-related increase was seen in fractional anistropy (P < .001, for both). CONCLUSION Diffusion-tensor imaging shows the columnar microstructure of the physis and adjacent metaphysis, and provides further insight into normal growth.
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Affiliation(s)
- Camilo Jaimes
- From the Department of Radiology, The Children's Hospital of Philadelphia, 34th & Civic Center Blvd, Room 3NW, Philadelphia, PA 19104 (C.J., J.I.B., J.D., V.H.F., D.J.); and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa (J.I.B., V.H.F., D.J.)
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Jaimes C, Chauvin NA, Delgado J, Jaramillo D. MR Imaging of Normal Epiphyseal Development and Common Epiphyseal Disorders. Radiographics 2014; 34:449-71. [DOI: 10.1148/rg.342135070] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Skeletal Development of the Proximal Humerus in the Pediatric Population: MRI Features. AJR Am J Roentgenol 2014; 202:418-25. [DOI: 10.2214/ajr.13.10711] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Cartilage imaging in children: current indications, magnetic resonance imaging techniques, and imaging findings. Radiol Clin North Am 2013; 51:689-702. [PMID: 23830793 DOI: 10.1016/j.rcl.2013.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Evaluation of hyaline cartilage in pediatric patients requires in-depth understanding of normal physiologic changes in the developing skeleton. Magnetic resonance (MR) imaging is a powerful tool for morphologic and functional imaging of the cartilage. In this review article, current imaging indications for cartilage evaluation pertinent to the pediatric population are described. In particular, novel surgical techniques for cartilage repair and MR classification of cartilage injuries are summarized. The authors also provide a review of the normal anatomy and a concise description of the advances in quantitative cartilage imaging (ie, T2 mapping, delayed gadolinium-enhanced MR imaging of cartilage, and T1rho).
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