Central ray deficiency with extensive syndactyly: a dilemma for classification

Split Hand Foot Malformation (SHFM) (cleft hand/foot, central ray deficiency) is a complex, highly variable anomaly involving the hands and/or feet. A clinical epidemiologic study of split hand/foot (central ray deficiency) of the Manitoba population identified a subset of patients who did not present with either typical or atypical split hand. Clinically, some patients presented with "mitten hand" syndactyly; the deficiency was not recognized before imaging. In this paper, we identify additional similarly affected literature cases, review existing classifications of split hand and syndactyly and attempt to classify these patients. This group presents a challenge for classification and genetic counseling. General classifications permit inclusion of patients with diverse phenotypes; however, details are overlooked. Osseous fusions and disorganization of osseous components complicate classification. Many of these patients had findings that overlapped different subtypes within existing classifications. This cohort highlights the importance of imaging patients with distal limb anomalies. An effective classification scheme should include relevant clinical and radiographic findings in order to assist clinicians following these patients.

Discrepancies in upper and lower limb patterning in split hand foot malformation

Discrepancies in upper and lower limb patterning in split hand foot malformation. Split hand foot malformation (SHFM) is genetically heterogeneous with five loci mapped to date. Highly variable in presentation, it can occur as an isolated finding or with other anomalies. The genetic heterogeneity and clinical variability make genetic counselling of SHFM families challenging. By establishing genotype/phenotype correlations, one can provide insight into responsible developmental genes and help to direct mapping efforts and target genetic testing, ultimately providing more accurate information for family members. Preaxial involvement of the upper extremities was a significant discriminating limb-specific variable in our analysis of genetically mapped SHFM cases. This finding, which was originally identified through descriptive epidemiology, was subsequently confirmed by discriminant function analysis (p < 0.0001) to be a significant locus discriminator. Preaxial involvement of the upper extremities was most commonly seen at the SHFM3 locus mapped to chromosome 10q24 (OMIM 600095) and consisted of proximally placed thumbs and/or triphalangeal thumbs (TPT), preaxial polydactyly and/or absence of the first ray. These patients' feet, however, tended to show a classical central longitudinal deficiency without a significant preaxial component. This article discusses this discrepant clefting pattern between the upper and lower extremities and proposes potential mechanisms.

Paediatric personnel extremity dose study

Concern has been expressed in paediatric radiology regarding the magnitude of the extremity dose received by attending personnel during routine fluoroscopic procedures and CT. Common procedures that may be of short duration in adults can be quite the opposite in paediatric patients. The extremities of attending personnel are more likely to be exposed to the primary beam and for a longer period of time owing to a variety of reasons such as assisting in the procedure or physically restraining the patient during the examination. During the period mid 1998 to mid 2000, two paediatric radiologists, four senior radiographers and two paediatric nurses were monitored using ring thermoluminescent dosemeters (TLDs). Each participant wore the ring TLD on either the left or right ring finger, depending on which hand the individual favoured. Left/right asymmetrical studies were not conducted, nor were records kept of whether an examination used a grid or gridless technique. Initial apprehension about higher paediatric fluoroscopic and CT extremity doses was dispelled as a result of this quantitative dosimetric study.

Analysis of the value of imaging as part of the follow-up of splenic injury in children

OBJECTIVE

A recent article suggested that routine follow-up imaging is still frequently used in the conservative management of splenic trauma in children. The purpose of this study was to use decision analysis to assess the value of routine imaging as part of the long-term follow-up of splenic injury in children managed nonoperatively.

METHODS

A literature review (1970-1999) on the management of blunt splenic trauma in children was performed. Data, including the use of follow-up imaging and the occurrence of delayed splenic rupture and death, on those patients managed nonoperatively were collected. The data were used to construct a decision tree. A Poisson distribution was used to determine the risk of delayed splenic rupture.

RESULTS

Information was extracted from 26 cohort studies. Nineteen of these studies were retrospective and six were prospective. One study had both retrospective and prospective arms. The study population consisted of 1,083 children. Of these patients, 920 (85 %) underwent routine follow-up imaging (US, CT, or scintigraphy). Follow-up imaging was either not performed or selectively performed in 163 patients (15 %). No cases of post-discharge splenic rupture or death were encountered in any of these groups. The maximum risk of delayed splenic rupture in the entire group was 0.3 % (0-3.7 cases).

CONCLUSION

The risk of delayed splenic rupture following blunt injury in children is very low, and is apparently unaffected by imaging protocols. No deaths, even in cases of delayed presentation, were identified in our study. These findings do not support the use of routine follow-up imaging of children with blunt splenic trauma.

Third case of cerebral, ocular, dental, auricular, skeletal anomalies (CODAS) syndrome, further delineating a new malformation syndrome: first report of an affected male and review of literature

CODAS syndrome (MIM# 600373) is a rare multiple congenital anomalies syndrome. The disorder is highly distinctive with characteristic features consisting of developmental delay, cataracts, unusual enamel projections, overfolded and crumpled ears, epiphyseal dysplasia, and dysmorphic features (grooved nose, ptosis). To date, there have been two affected female children reported. The first was a Canadian girl of Mennonite descent, reported by our group, and the second was a girl from Brazil. The etiology and pattern of inheritance of CODAS is unknown. Herein we report a third affected child, a Canadian male infant of Mennonite ancestry. The child, now two years old, exhibits ptosis, cataracts, overfolded ears, grooved nasal tip, dental projections, developmental delay, and characteristic skeletal anomalies. The findings are characteristic for CODAS syndrome. All investigations including karyotype, metabolic screening, peroxisomal studies, and studies of cholesterol biosynthesis were normal. The underlying defect responsible for CODAS syndrome remains unknown. Many of the features suggest a possible underlying collagen gene defect. The fact that this child is the second child from the Manitoba Mennonite community, a genetic isolate, suggests the possibility of autosomal recessive inheritance. To date, there has not been a familial recurrence.

A novel quality assurance method in a university teaching paediatric radiology department

Primary diagnostic equipment in a paediatric radiology department must perform at optimal levels at all times. The Children's Hospital Radiology Department in Winnipeg, Canada, has developed an impartial means of reporting radiographic image quality. The main objectives of this study programme were two-fold. First, to monitor diagnostic X-ray equipment performance, and second, to improve the resultant image quality as a means of implementing the fundamental concepts of continuous quality improvement. Reading radiologists completed a quality assurance (QA) card when they identified a radiographic image quality problem. The cards were subsequently collected by the clinical instructor who then informed, in confidence, the radiographers of the written comments or concerns. QA cards have been conspicuously installed in the paediatric radiology reading room since the middle of 1993. Since its inception, equipment malfunction has been monitored and indicators for improving image quality developed. This component of the QA programme has shown itself to be a successful means of communicating with radiographers in maintaining superior image quality.

Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: a Canadian experience

OBJECTIVES

To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself.

METHODS

A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression.

RESULTS

One thousand one hundred sixty-four children were included in the study. One hundred seventy-one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan.

CONCLUSIONS

Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.

Features of calcaneonavicular coalition on coronal computed tomography

OBJECTIVE

To determine the findings of calcaneonavicular coalition on coronal CT.

DESIGN

We retrospectively reviewed the CT scans of 14 calcaneonavicular coalitions in eight patients. All coalitions were visible on the axial scans, and the diagnosis was confirmed by surgery in five patients. These CT scans were compared with scans of ten normal feet.

RESULTS

We identified two features of calcaneonavicular coalition on coronal CT: lateral bridging (an abnormal bony mass lateral to the head of the talus) and rounding of the talus. All eight patients demonstrated at least one of these two findings.

CONCLUSION

Although calcaneonavicular coalition is best seen on axial CT scans of the feet, there are two abnormalities, lateral bridging and rounding of the head of the talus, which should suggest the diagnosis on coronal CT scans.

Sir William Osler and John Hunter

"John Hunter ..... the man in whose phenomenal personality may be seen all the distinctive traits of modern medicine, and the range of whose mighty intellect has had few, if any, equals since Aristotle".

Cause and clinical characteristics of rib fractures in infants

OBJECTIVE

Rib fractures are uncommon in infancy and, when diagnosed, often raise the suspicion of child abuse. However, the prevalence of other causes of rib fractures has not been well defined. The purpose of this study was to determine the causes and clinical presentations of rib fractures in infants <12 months old.

METHODS

Retrospectively, we identified all infants with rib fractures under 12 months old over a 3-year period using computerized databases at the Children's Hospital Medical Center in Cincinnati, Ohio and at the Children's Hospital, Winnipeg, Manitoba, Canada. Data extracted from the individual patient charts included: age, sex, chief complaint, number and location of rib fractures, associated injuries, birth history, history of cardiopulmonary resuscitation, and any evidence of bone dysplasia. After the chart review and a review of the radiographs by a pediatric radiologist, all fractures were determined to be attributable to one of the following causes: child abuse, birth injury, bone fragility, or accidental trauma. A determination of abuse was made when there were other injuries indicative of abuse, there was no clinical or radiographic evidence of bone fragility, there was a confession of abuse, when no reasonable history of trauma was provided, or when the history was not plausible to explain the rib fractures. Standard practice at these hospitals involves obtaining skeletal surveys on all children <2 years old when abuse is suspected. The child abuse team, which consists of physicians, nurses, and social workers, conducts these investigations and works closely with police in evaluating these children.

RESULTS

Thirty-nine infants with rib fractures were identified. Thirty-two (82%) were caused by child abuse. Three (7. 7%) were attributable to accidental injuries, 1 (2.6%) was secondary to birth trauma, and 3 (7.7%) were attributable to bone fragility. All 3 infants with fractures from accidental injury had sustained notable trauma (a motor vehicle collision, a forceful direct blow, and a fall from a height). Of the 3 infants with fractures secondary to bone fragility, 1 infant had osteogenesis imperfecta, 1 infant had rickets, and 1 infant, who was born at 23 weeks' gestation, had fragile bones attributable to prematurity.

CONCLUSIONS

Most rib fractures in infants are caused by child abuse. Although much less common, rib fractures can also occur after serious accidental injuries, birth trauma, or secondary to bone fragility. A thorough clinical and imaging evaluation is mandatory.

Premature epiphyseal fusion and degenerative arthritis in chronic recurrent multifocal osteomyelitis

A 9-year-old boy was diagnosed with chronic recurrent multifocal osteomyelitis affecting multiple sites. During an 8-year follow-up he developed premature closure of a distal radial epiphysis and degenerative changes in the adjacent radiocarpal joint.

The axolotl as an animal model for the comparison of 3-D ultrasound with plain film radiography

We assessed the usefulness of an animal model, the axolotl (Ambystoma mexicanum), in comparing 3-D ultrasound (3-D US) and plain film radiographs. Hindlimbs were amputated from 5 animals, at either the zeugopodial or stylopodial level, and each regenerating limb was imaged 16 times with 3-D US and 14 times with plain film X ray over 315 days. US images were acquired with a Siemens Sonoline Versa Pro and a 10-MHz linear array transducer. For 3-D US images, the probe was translated in a motor-driven linear stage while images were digitized. The regenerating tibia and fibula bones were detected on 3-D US an average of 37 days earlier than on plain film radiography, and regenerating phalangeal bones were detected on 3-D US an average of 18 days earlier. After 120 days, both imaging modalities consistently showed the bones. The average bone growth rates for the tibia and fibula were 0.019 +/- 0.001 mm/day and 0.019 +/- 0.001 mm/day, respectively.

Biliary tract complications of side-to-side without T tube versus end-to-end with or without T tube choledochocholedochostomy in liver transplant recipients

BACKGROUND

Biliary anastomotic complications remain a major cause of morbidity in liver transplant recipients, ranging between 10% and 50% in large clinical series. An end-to-end choledochocholedochostomy with or without T tube (CDCD EE with T tube and CDCD EE w/o T tube) and a Roux-en Y choledochojejunostomy have been standard methods for biliary drainage.

METHODS

The objectives of this retrospective study were to: (1) evaluate the incidence of biliary tract complications using a new method of side-to-side choledochocholedochostomy without T tube (CDCD SS w/o T tube) and (2) compare the results of CDCD SS w/o T tube with those of CDCD EE with T tube and CDCD EE w/o T tube. From September 1991 through June 1996, 279 orthotopic liver transplants were performed in 268 patients and followed through December 1996 (minimum of 6 months' follow-up). A total of 227 CDCD anastomoses in 220 patients were studied (7 retransplants > 30 days): CDCD EE with T tube (n=124), CDCD EE w/o T tube (n=44), and CDCD SS w/o T tube (n=59).

RESULTS

Sixty-nine biliary complications were observed in 220 patients (30%). Anastomotic and/or T-tube leaks were seen in 43 patients (19%), and anastomotic strictures were found in 26 patients (12%). Forty patients (18%) required percutaneous or endoscopic stent placement (6%) or surgical interventions (12%). CDCD EE with T tube had the highest incidence of biliary leak requiring rehospitalization but the lowest anastomotic stricture and intervention rate and the lowest 6-month mortality rate.

CONCLUSIONS

CDCD EE with T tube was superior to CDCD EE or CDCD SS w/o T tube despite the increased number of rehospitalizations. CDCD SS w/o T tube did not offer significant advantages over conventional biliary anastomotic techniques.

SAMS: provisionally unique multiple congenital anomalies syndrome consisting of short stature, auditory canal atresia, mandibular hypoplasia, and skeletal abnormalities

We report on a young Mennonite child born with short stature, atresia of the external auditory canal, mandibular hypoplasia, and skeletal anomalies. The skeletal defects consist of bilateral humeral hypoplasia, delayed ossification of the pubic rami, and the previously unreported anomaly of humeroscapular synostosis. This girl is the product of a consanguineous mating. This phenotype is unique and does not match that of any previously described condition.

Pulmonary blastomycosis in children: findings on chest radiographs

OBJECTIVE

The purpose of this study was to identify characteristic radiographic findings in children with pulmonary blastomycosis.

SUBJECTS AND METHODS

We reviewed the charts and radiographs of 18 children with culture-proven acute pulmonary blastomycosis. The 10 boys and eight girls were from 1 to 16 years old. Sixteen were Native Canadian Indians, and two were white. All available chest radiographs, including those obtained in follow-up after treatment was terminated, were reviewed by a pediatric radiologist. Consolidation was classified by location and extent, and other abnormalities were noted.

RESULTS

Initial chest radiographs showed consolidation in 16 patients. Seven patients had single lobe involvement, most commonly of the left lower lobe. Nine patients had multiple lobe involvement. The left lower lobe was most commonly involved in these cases, but the middle lobe was most severely affected. The upper lobes were involved only in children with multiple lobe disease and were only mildly affected. Cavitation developed in two patients, followed by bronchogenic spread of the disease. Pleural effusions were seen in three patients; two also had rib lesions. Hilar adenopathy developed in two children. Five patients had radiographs available, which had been obtained more than a year after onset, and three of these were abnormal.

CONCLUSION

The most common radiologic finding in children with pulmonary blastomycosis is pulmonary consolidation in one or several lobes, which may undergo cavitation. Lymphadenopathy and pleural effusions are uncommon. Chronic abnormalities may develop.

A criterion for a true lateral radiograph of the elbow in children

In the search for a fracture of the elbow in children, the position of the anterior humeral line is a valuable aid. It has been stated that a true lateral radiograph is required to use this sign, although no criteria for assessing true laterality have been described. To develop such criteria, the authors examined 74 lateral radiographs of the elbow for 42 patients ranging in age from 9 months to 5 years, 9 months. Thirty-five of the patients did not have supracondylar fractures, and 7 did. In all of the radiographs the direction and degree of rotation, as well as the position of the anterior humeral line, were assessed relative to a series of radiographs of a cadaveric humerus in standardized positions. Examination of the humeral anatomic features in the radiographs showed that superimposition of the posterior supracondylar ridges of the humerus is the best means of confirming true laterality. This criterion is easily applied to lateral radiographs of the elbow in children. Of the radiographs reviewed, only seven were considered to represent true lateral views. Of those exposed in other degrees of rotation, the anterior humeral line gave a false indication of fracture in 19.

Staging of healing of femoral fractures in children

Although the rate of fracture healing has been studied in adults, little such work has been done in children. The authors' objective was to develop staging criteria for assessing callus formation in fractures in children and to determine the relation between the age and sex of the patient and callus formation. They studied callus formation in healing fractures of the femoral diaphysis in 25 patients, 15 boys and 10 girls, ranging in age from birth to 14 years. The patients were selected on a random basis from children presenting with femoral fractures (and no other injuries) to a tertiary-care pediatric hospital in Winnipeg over the period 1988 to 1991. The following staging criteria were developed from other examples of femoral fracture: stage 1, earliest radiographically visible calcification of the callus; stage 2, callus completely bridging the fracture site; and stage 3, mature callus. For the patients in the study, the average times to reach stages 1, 2 and 3 were 11.7, 18.7 and 55.3 days respectively. The sex of the patient had no effect on callus formation. The final stage of healing appeared to take longer with increasing patient age, although this observation was not statistically significant.

Abnormal ossification of the hyoid bone in cleidocranial dysplasia

Radiographs of the hyoid region of 13 patients with cleidocranial dysplasia were reviewed. In all but one the hyoid bone was less ossified than normal. Delayed ossification, affecting the skull, the teeth, the pelvis and the extremities, is a known, frequent manifestation of this abnormality.

Ossification of the hyoid bone during childhood

Normal ossification of the hyoid bone was studied on the basis of postpartum radiographs of 10 stillborn children and radiographs of the cervical spine or the lateral neck of 86 children ranging in age from newborn to 16 years old. None of the patients was suspected of having any abnormality of skeletal ossification. Ossification of the hyoid was seen only after 30 weeks' gestation. The body of the hyoid was ossified in all infants older than 4 months, and the greater cornua were ossified in all those older than 6 months. Ossification of the lesser cornua did not appear in children less than 15 years of age. Normal measurements for the body of the hyoid and the greater cornua were determined.

Contact thermography in the diagnosis of childhood migraine

The objective of our prospective study was to assess the role of contact thermography in children with migraine. Contact thermograms were done in 54 children aged 4.2-16.5 years (median 10.5 years), who were seen for headache and on 10 age-matched controls, between July and December 1991. Thermograms were interpreted as definitely normal, equivocally normal, equivocally abnormal, and definitely abnormal by a radiologist who was blinded to clinical information. Forty-eight children had the test between headaches; of these, four out of 26 patients (15%) who had migraine without aura and 3 out of 14 children (21%) who had migraine with aura had definitely abnormal thermograms. Nine out of 10 normal controls had definitely normal thermograms. The sensitivity of contact thermography in the diagnosis of childhood migraine, when done between headaches, was low in our study.

Restrictive dermopathy

Restrictive dermopathy is an inherited syndrome characterized clinically by severe growth retardation, abnormal skin, characteristic facies, and multiple congenital contractures. Distinctive radiologic features include deficient mineralization of the clavicles and the skull, overtubulation and frequent modeling defects of the long bones, and occasional abnormalities of the ribs and scapulae.

Types and complications of femoral neck fractures in children

This multicenter collaborative study was undertaken to review the types and complications of femoral neck fractures in children. It is a retrospective clinical and radiological review of 108 femoral neck fractures. Cases originated from four different pediatric hospitals. All the patients had plain radiographs. Fractures occurred at all ages (one day to 18 years), and 63% of the patients were boys. Forty-nine fractures were traumatic; 37 were pathologic, 19 were insufficiency fractures; and three were fatigue fractures. Unless the underlying bone was abnormal, significant high velocity trauma, fall from a height or other severe violence was required to fracture the femoral neck. A unicameral bone cyst was the underlying lesion in 40% of pathologic femoral neck fractures and malignancy in 35%. Osteoporosis as in myelodysplasia, osteogenesis imperfecta and from other causes was responsible for 52% of insufficiency fractures. Because of the unique osseous and vascular anatomy of the femoral head and neck in the growing child, these fractures have a high incidence of complications. Complications included avascular necrosis 13%, premature closure of the epiphyseal plate 12%, varus deformity 8.3%, and nonunion 3.7%. Unless there is a clear history of significant violence, a cause for a femoral neck fracture should be sought, e.g. an underlying bone lesion or a metabolic bone disease. These fractures are rare, but are serious injuries since their complications may lead to a life-long disability.

Heterotopic ossification in children after iliopsoas release

Heterotopic calcification or ossification of the soft tissues adjacent to the lesser trochanter was observed in the radiographs of 4 patients during a retrospective review of the records of 68 patients with Perthes' disease. This abnormality has since been seen in one other patient with Perthes' disease and in five with spastic quadriplegia. All 10 patients are known to have undergone iliopsoas release as part of adductor tenotomy. The authors believe that the heterotopic ossification is related to the surgery.

The radiology of juvenile rheumatoid arthritis. A review of the English language literature

The radiologic abnormalities seen in patients with juvenile rheumatoid arthritis (JRA) include disturbances of growth, various types of joint destruction, abnormalities of bone density, periostitis, and soft tissue abnormalities. We review the English language literature, which deals with the radiologic abnormalities in general, and at specific sites. We also review briefly radiologic abnormalities seen in other organ systems. The role of the other imaging modalities in the assessment of JRA is discussed.

Traumatic pseudodislocation of the acromioclavicular joint in children. A fifteen year review

Traumatic acromioclavicular separation in the skeletally immature patient is frequently overdiagnosed and overtreated. Fifty-eight children, aged 5 to 16 years, who presented over a 15 year period with injuries to the distal clavicle, were reviewed retrospectively. The majority showed coracoclavicular widening radiographically, suggesting acromioclavicular separation. In 45 cases, a distal clavicular fracture was identified, while an acromioclavicular separation without fracture was initially diagnosed in 13. Long-term followups of these patients demonstrate excellent results with conservative management. "Pseudodislocation" involves a clavicular fracture of the lateral metaphysis or metaphyseal epiphyseal separation and not an acromioclavicular disruption. This pseudodislocation of the acromioclavicular joint in the skeletally immature patient must be differentiated from the adult counterpart to avoid unnecessary operative intervention.

Radiologic features of congenital transverse deficiency of the forearm

The records of fifteen patients (11 girls and 4 boys) with a congenital transverse deficiency of the forearm were studied. In 11 patients the lesion was on the left. The deficiency occurred in the proximal third of the forearm in 13 patients. The radius and the ulna were usually bowed, and their shafts were sometimes irregular. The radial head was dislocated in six patients, and minor abnormalities occurred in the distal humerus in five and the proximal ulna in five.

Forearm deformities in multiple cartilaginous exostoses

Sixteen patients with 20 forearm deformities were reviewed. The deformities were classified into three types. The degree of ulnar tilt of the radius, ulnar displacement of the carpus, and relative ulnar shortening were determined. The severity of the deformity correlated with these measurements. Metacarpal lengths were also measured. Significant metacarpal shortening without exostoses was seen in 10 of 11 patients and with exostoses remote from the metaphysis in 10 of 13 patients. Metacarpal shortening correlated with the type and severity of deformity.

Newly recognized syndrome of cerebral, ocular, dental, auricular, skeletal anomalies: CODAS syndrome--a case report

We report on a child with a unique constellation of congenital anomalies suggesting a new syndrome. These consist of developmental delay; craniofacial abnormalities, including bilateral cataracts, ptosis, median nasal groove, malformed ears with associated neurosensory hearing loss; dental anomalies consisting of anomalous cusp morphology with unusual pointed extensions and delayed tooth eruption; short stature with marked delay in epiphyseal ossification; coronal clefts involving vertebrae T11-S2; and dislocated hips. A literature search and use of a computer-assisted syndrome-identification program failed to uncover an identical case.

Spondylometepiphyseal dysplasia congenita, Strudwick type

A case of spondylometepiphyseal dysplasia congenita, Strudwick type is presented. At birth, this condition cannot be distinguished from spondyloepiphyseal dysplasia congenita. Features in common include delayed ossification of the public bones and proximal femoral epiphyses, coxa vara, odontoid hypoplasia and lumbar lordosis. The distinguishing radiologic feature of this condition is the striking irregularity of long bone metaphyses which develops during infancy.

Computer assisted analysis of hand radiographs in infantile hypophosphatasia carriers

Hand radiographs of 49 carriers of infantile hypophosphatasia and 67 non-carriers were evaluated using two Apple IIe Computer Programs and an Apple Graphics Tablet. CAMPS (1) was used to determine the bone lengths and calculate the metacarpophalangeal profiles. A newly developed program (ADAM) was used to determine bone density based on percent cortical area of the second metacarpal. Carriers of infantile hypophosphatasia had significantly less dense bones.

The toddler's fracture revisited

The authors have reviewed our experience with 37 cases of toddler's fracture. This fracture of the distal tibia occurs in 1 to 4 year-old-children. History of trauma is usually trivial and the physical findings and radiological appearance are often subtle. The latter consists of a faint oblique lucent line crossing the distal tibia and terminating medially. It is usually seen on the anteroposterior view, poorly seen on the lateral and well seen on the internal oblique. Initial radiographs may be normal. A similar fracture of the midshaft of the tibia was associated with child abuse. Treatment consists of immobilization for a few weeks to protect the limb and to relieve pain. Diagnosis requires a high index of suspicion and is important because it obviates the need for investigations to rule out more sinister etiologies such as tumor or infection. The finding of a midshaft tibial fracture may indicate child abuse.

RO 23-6457 prolongs survival of vascularized allografts in rodents and primates

The ability of RO 23-6457, a retinoid compound with marked in vitro immunosuppressive properties, to prolong vascularized allografts was examined in several in vivo transplantation models. In the murine heterotopic heart model, efficacy was shown in two H-2 incompatible strain combinations, with indefinite graft survival at some doses. In the rat heterotopic heart model, oral administration prolonged Wistar-Furth grafts in Lewis hosts an average of 1 week, with no long-term survivors at a variety of doses. Given subcutaneously, grafts were further prolonged, but the compound proved toxic. In a bilaterally nephrectomized renal transplant model in cynomolgus monkeys treated intravenously at a dose of 2 mg/kg/day, host survival was prolonged to 18, 32, 33, and 74 days, compared with 11, 11, 12, 13, and 26 days in untreated controls (P less than 0.05 by rank-sum testing). The three shorter surviving recipients died from anorexia and weight loss with normal renal function, while the longest survivor rejected its kidney when exhaustion of iv sites precluded further treatment. The toxic effects of the compound resemble the syndrome of hypervitaminosis A. RO 23-6457 will prolong graft survival as a single agent, justifying further preclinical testing and efforts to reduce toxicity.

Osteomyelitis of the tarsal bones in children

The radiographic findings in seven children with tarsal osteomyelitis are described. The bones involved were the calcaneus, talus, cuboid, and navicular. The lesions appeared as single, subchondral, reasonably well-defined round lucencies measuring up to 12 mm in diameter. Bone scans were positive. The lesions healed slowly with surrounding sclerosis but no periosteal reaction.

The role of a primate model of renal transplantation in the development of new monoclonal antibodies

In recent years, a detailed understanding of the cellular and molecular basis of the immune response has been achieved. These advances, coupled with the technology for producing monoclonal antibodies, have made possible to consider highly specific and potentially powerful methods of immunosuppressive treatment. This promise of potent and specific treatment has not been entirely fulfilled on clinical practice. A preclinical nonhuman primate model of renal transplantation is described. The model has been used to investigate two monoclonal anti-IL-2 receptor antibodies, one of which was found to be effective. Anti-Tac, an lgG2a mouse antihuman monoclonal antibody, prolongs graft survival in cynomolgus monkeys from 12 to 19 days. The role of such a model in bringing new monoclonal antibodies to the clinic is described.

Interleukin 2 receptor expression on peripheral blood lymphocytes in association with renal allograft rejection

Periodic assay of IL-2 receptor expression on the surfaces of peripheral blood lymphocytes might provide information predictive of in vivo immunologic events. This study compares two methods of determining IL-2 receptor expression after renal transplantation in cynomolgus monkeys. The first utilized single color staining of peripheral blood mononuclear cells with mouse anti-human IL-2 receptor monoclonal antibody followed by a fluorescein-labeled goat anti-mouse IgG antibody. Epics C cell sorter windows were set to count cells of the size and granularity of normal lymphocytes. The second utilized two-color staining with fluorescein-labeled anti-IL-2 receptor antibody, combined with phycoerythrin-labeled anti-CD4 antibody or with phycoerythrin-labeled anti-CD8 antibody. Two-color staining allowed the sorter windows to be enlarged to count all mononuclear cells, regardless of size or granularity, without introducing the contaminating effects of monocytes. Data obtained from single-color staining showed no consistent or significant expression of the IL-2 receptor on peripheral lymphocytes in association with the rejection process. Data obtained from two-color staining revealed an increase of IL-2 receptor expression on peripheral T cells of at least 10% from the postoperative baseline, which preceded the creatinine rise from allograft rejection in 13 of 13 animals. Increases in IL-2 receptor expression on T cells were not specific to rejection, however. Some animals in which treatment produced a delay of rejection showed a transient rise in IL-2 receptor expression around post-transplant day 5, which was not followed by a rise in creatinine. The two-color staining technique described provides a sensitive means of detecting IL-2 receptor expression in vivo and documents the association of increases in IL-2 receptor expression on T cells with rejection.

Shoulder deformities from obstetrical brachial plexus paralysis

Abnormalities are described in the shoulders of 11 patients up to 17 years of age who have chronic brachial plexus paralyses from birth injuries. These abnormalities include a poorly formed and hypoplastic humeral head, a short abnormally formed clavicle, and a hypoplastic elevated scapula with a shallow glenoid fossa, inferiorly directed coracoid process, and abnormally tapered acromion. Four also had subluxated shoulders.

Calcification of axillary lymph nodes following BCG vaccination

Axillary lymph node calcification was found in 18 children following BCG vaccination. Five of these also had symptomatic adenitis. The calcifications involved one to four nodes and appeared as discrete, oval densities. They disappeared over the course of several months in three patients. No axillary lymph node calcification was seen on chest radiographs of 60 other children who had had BCG vaccination in the neonatal period.

Prolongation of primate renal allograft survival by anti-Tac, an anti-human IL-2 receptor monoclonal antibody

In an effort to produce specific immunosuppression through the targeting of those lymphocytes expressing cell surface interleukin 2 receptors in response to an allograft, the anti-human IL-2 receptor monoclonal antibody anti-Tac was administered to cynomolgus monkeys receiving renal transplants. The data demonstrate that anti-Tac produces a significant delay in renal allograft rejection and prolongs host survival in cynomolgus monkeys. Though higher doses of anti-Tac produce modest delays in rejection, there was a surprising finding of greatly prolonged survival in three of five monkeys treated with much lower doses of anti-Tac. Anti-Tac was not shown to be synergistic with cyclosporine in this model. Animals treated with anti-Tac developed high titers of antibodies against the murine monoclonal antibody after 6-8 days of treatment, associated with the disappearance of plasma anti-Tac staining of activated lymphocytes as measured by flow cytometry. The data confirm the utility of the IL-2 receptor as a target for immunosuppressive therapy, and suggest that investigations of dosage and of methods to reduce the immunogenicity of anti-IL-2 receptor agents may be beneficial.

Growth disturbances in the hands following thermal injuries in children. 2. Frostbite

Nine children who had growth abnormalities of their hands following frostbite were studied. In all nine there was shortening of distal phalanges and some adjacent middle phalanges. Proximal phalanges and metacarpals were rarely involved. Epiphyseal abnormalities included destruction, premature fusion, and fragmentation. Other findings included irregularity of the distal ends of phalanges, abnormal alignment, joint abnormalities, and soft tissue swelling.

Growth disturbances in the hands following thermal injuries in children. 1. Flame burns

Five children developed growth disturbances following severe burns of their hands. Joint abnormalities, amputations, and periosteal reaction were seen on radiographs, and all had premature epiphyseal fusion in several phalanges or metacarpals, a finding rarely described previously.

Radiologic features of Dévé's accessory lobe

In 10-15% of the population a fissure, situated at the same level as the minor fissure, partially or completely separates the superior segment from the basal segments of the lower lobe, more commonly on the right. A review of 25 patients showed that the accessory lobe produced by this fissure has a characteristic appearance when consolidated or collapsed. On the frontal view the consolidation is sharply marginated inferiorly by the accessory fissure, and it does not obscure the mediastinal margin. On the lateral view it has a triangular shape bounded by the oblique and accessory fissures. When there is loss of volume the accessory fissure is elevated.

Possible prenatal hydantoin effect in a child born to a nonepileptic mother

We describe a child who was born with marked digital hypoplasia of his right hand. Although the mother was not an epileptic, the child was exposed in utero to diphenylhydantoin.

Zimmerman-Laband syndrome and profound mental retardation

A young man was diagnosed as having Zimmerman-Laband syndrome (ZLS) on the basis of gingival fibromatosis and absence of nails on thumbs and halluces in addition to other anomalies. He also had profound mental retardation.

Cystic fibrosis in the adolescent and adult

Modern comprehensive therapy for CF now allows the survival of patients into adulthood. In addition, more patients are being diagnosed for the first time in adolescence or early adulthood. As a result, over 20% of all CF patients are aged 18 years or older. The clinical and radiologic features of the older patients differ from those of pediatric patients and are discussed in this article. However, as with the pediatric patients, chronic lung disease remains the major cause of morbidity and is, almost uniformly, the cause of death in adolescent and adult CF. The plain chest radiograph remains a vital tool not only for diagnosis but as a simple method for establishing a baseline at diagnosis and quantifying serial changes as the patient ages.

Is bronchiolitis in infancy an antecedent of chronic lung disease in adolescence and adulthood?

Acute bronchiolitis in infancy appears to be associated with persistence of wheezing or subsequent asthma in later life. Chest imaging techniques have demonstrated persistent structural lung damage such as atelectasis, bronchiectasis, and obliterative bronchiolitis among survivors of the more severe forms of bronchiolitis. In addition, in a significant number of survivors without demonstrable structural damage, pulmonary function studies have revealed a spectrum of disturbances including air-trapping, reduced air flow at low lung volumes, hypoxemia (all indicating disease in the small airways), and bronchial hyperreactivity. However, it has not yet been proven definitively whether the relationship between severe bronchiolitis in infancy and chronic obstructive lung disease is causal or noncausal. Further prospective clinical studies are needed to resolve this question.

Orthopaedic manifestations of leukemia in children

Acute leukemia of childhood may present with various clinical manifestations that mimic orthopaedic conditions. The osseous radiographic abnormalities of this disease, although well described in the literature, are not pathognomonic, and certain changes may not be as frequent as was previously thought. In a retrospective study, we reviewed the cases of 107 patients, less than eighteen years old, who had been seen at the Winnipeg Children's Hospital. The mean follow-up was 4.6 years for the fifty-eight patients who were still alive and 2.0 years for the forty-nine non-survivors. In twenty-two (20.6 per cent) of the patients, the presenting complaints were pain in the extremities, back pain, osteomyelitis, septic arthritis, or fracture. The radiographic abnormalities, which were present in forty-seven (43.9 per cent) of the children at the time of diagnosis, were osteopenia, lytic lesions, metaphyseal bands, periosteal new bone, and sclerotic lesions. Since the initial symptoms of leukemia commonly involve the musculoskeletal system, a high index of suspicion must be maintained by orthopaedic surgeons.