Adducted thumb as an isolated morphologic finding: an early sonographic sign of impaired neurodevelopment: A STROBE compliant study

Fetal adducted thumbs have been described in association with hydrocephalus and other abnormalities, but in cases without other structural malformations the determination of prognosis and recurrence risk is challenging. The aim of our study is to analyze the characteristics, natural history, and postnatal outcome of such cases.A retrospective study was conducted over a period of 4 years in a tertiary referral center. All fetuses diagnosed as adducted thumbs without other structural malformations comprised the study group. Prenatal sonographic features and neonatal outcome are documented.There were 4 cases of fetal adducted thumbs diagnosed during the study period. No cases demonstrated other structural malformations throughout the gestation. A smaller head was noted in 2 cases during the follow-up, and all cases presented with polyhydramnios on the first or ensuing scans. Three cases died after birth due to swallowing or breathing difficulty, and the surviving 1 showed convulsion and mental retardation.Fetal adducted thumb might be an early and specific sonographic marker of impaired neurodevelopment. Close follow-up and genetic investigation should be performed in these cases. Ultrasound examination plays an important role in the prenatal diagnosis and counseling of cases without detailed prenatal genetic analysis.

New case of trichorinophalangeal syndrome-like phenotype with a de novo t(2;8)(p16.1;q23.3) translocation which does not disrupt the TRPS1 gene

BACKGROUND

Trichorhinophalangeal syndrome (TRPS) is a rare autosomal dominant genetic disorder characterised by distinctive craniofacial and skeletal abnormalities. TRPS is generally associated with mutations in the TRPS1 gene at 8q23.3 or microdeletions of the 8q23.3-q24.11 region. However, three deletions affecting the same chromosome region and a familial translocation t(8;13) co-segregating with TRPS, which do not encompass or disrupt the TRPS1 gene, have been reported. A deregulated expression of TRPS1 has been hypothesised as cause of the TRPS phenotype of these patients.

CASE PRESENTATION

We report the clinical and molecular characterisation of a 57-year-old Caucasian woman carrying the t(2;8)(p16.1;q23.3) de novo balanced translocation. The proband presented with peculiar clinical features (severe craniofacial dysmorphism, alopecia universalis, severe scoliosis, mitral valve prolapse, mild mental impairment and normal growth parameters) that partially overlap with TRPS I. Mutational and array CGH analyses ruled out any genetic defect affecting TRPS1 or genomic alteration at the translocation breakpoint or elsewhere in the genome. Breakpoint mapping excluded disruption of TRPS1, and revealed that the chromosome 8q23.3 breakpoint was located within the IVS10 of the long intergenic non-coding RNA LINC00536, at approximately 300 kb from the TRPS1 5' end. Conversely, the 2p16.1 breakpoint mapped within a LINE sequence, in a region that lacks transcriptional regulatory elements. As a result of the translocation, nucleotide base pair additions and deletions were detected at both breakpoint junction fragments, and an evolutionarily conserved VISTA enhancer element from 2p16.1 was relocated at approximately 325 kb from the TRPS1 promoter.

CONCLUSIONS

We suggest that the disruption of the genomic architecture of cis regulatory elements downstream the TRPS1 5' region, combined with the translocation of a novel enhancer element nearby TRPS1, might be the pathogenetic mechanism underpinning the proband's phenotype. The clinical and genetic characterisation of the present subject allowed us to make a genetic diagnosis in the context of a known syndrome, contributing to a better comprehension of the complex transcriptional regulation of TRPS1 and TRPS ethiopathogenesis.

Carpal coalition with radioscaphoid synostosis and hypoplastic thumb

Carpal coalition is an anomaly that is usually discovered as an incidental finding on roentgenograms. The most common site is between the lunate and the triquetrum, though fusion of almost every combination of carpal bones has been reported. Carpal coalition can be isolated but has also been associated with numerous congenital malformation syndromes. In this article, we report the case of a 12-year-old boy with left-sided asymptomatic fusion of the trapezoid and trapezium, fusion of the radius and scaphoid, and hypoplasia of the thumb.

Ehlers-Danlos syndrome type VIB with characteristic facies, decreased curvatures of the spinal column, and joint contractures in two unrelated girls

Two unrelated girls, aged 11 and 14 years, with clinical manifestations of Ehlers-Danlos syndrome (EDS) type VIB, characteristic facies, skeletal abnormalities, and other features are described. They had Marfanoid habitus with pectus excavatum; fragile, hyperextensible, and readily bruisable skin with widened, atrophic scars; recurrent hematomas; generalized joint laxity; hypotonia; scoliosis; and mild delay of gross motor development. Lysyl hydroxylase deficiency was ruled out in Patient 1. Parental consanguinity was present in Patient 2. They both had, in early childhood, down-slanting palpebral fissures, drooping lower eyelids, short nose, small mouth, and long philtrum. Facial features that persisted included thick eyebrows, hypertelorism, strabismus, blue sclerae, low-set, and slanted ears, hypoplastic columella, high-arched palate, and thin upper lip. They had tubular stenosis of the phalanges, metacarpals, and metatarsals; decreased physiological curvatures of the spinal column with tall vertebrae; and joint contractures including talipes equinovarus and progressive talipes valgus. Their hearing of high-pitched sounds was impaired. They had constipation and recurrent cystitis with an enlarged bladder. In view of these findings, we propose that these two girls represent a clinically recognizable subgroup of EDS type VIB.

Torg-Winchester syndrome: lack of efficacy of pamidronate therapy

Torg-Winchester syndrome, which includes nodular arthropathy with osteolysis (OMIM 605156), is a condition associated with generalized osteoporosis. On the basis of usefulness of pamidronate in conditions with osteoporosis, we hypothesized that the drug will improve osteolysis and/or osteoporosis in this condition. After obtaining informed consent from the parents, two siblings affected with Torg-Winchester syndrome were administered intravenous pamidronate over a period of 3 years. The clinical status was monitored along with the bone mineral density (using radiographs and X-ray densitometry) to assess the effect of the drug. Clinically there was no improvement. Although the bone mineral density improved in axial skeleton, osteoporosis and osteolysis continued to worsen in the appendicular skeleton. We conclude that pamidronate does not improve peripheral osteolysis in multicentric osteolysis and nodular arthropathy caused by mutation in matrix metalloproteinase 2 gene.

Systemic sclerosis

Systemic sclerosis (scleroderma) is a rare generalized disorder of connective tissue origin. This condition is predominantly a clinical diagnosis, based on the clinical signs and symptoms. Here is a case report of 26-year-old female patient with the classical features of this disease. This case is reported for its rarity and variable expressivity. This article also reviews the literature of this uncommon condition.

Radiology of the hands: review and self-assessment module

OBJECTIVE

The educational objectives of this continuing medical education activity are for the reader to exercise, self-assess, and improve skills in diagnostic radiology with regard to the interpretation of radiographs, CT, and MRI of the hand and to improve understanding of the appropriate use of CT and MRI in evaluating lesions of the hand.

CONCLUSION

The conditions illustrated in this article include erosive osteoarthritis, sarcoidosis, metastatic calcification, and synovial sarcoma. This article is qualified by the American Board of Radiology (ABR) in meeting the criteria for self-assessment toward the purpose of fulfilling requirements in the ABR Maintenance of Certification.

Metacarpophalangeal pattern profile analysis in Rubinstein-Taybi syndrome

Metacarpophalangeal pattern profile (MCPP) was determined in 49 radiographs of 40 patients with Rubinstein-Taybi syndrome. Two recognizable hand profiles were seen, depending on the configuration of the thumb and on age. Patients with a straight thumb showed a short first proximal phalanx, and short third medial phalanx. Patients with a radially deviated thumb had a short first proximal phalanx. Depending on age, a relatively large (infancy) or markedly short (older patients) first distal phalanx was found. The similarity between the patients was high. A third group of patients did not show a particular hand profile, but only small hand bones. The pattern variability indices were high in all groups of patients. MCPP analysis in Rubinstein-Taybi syndrome seems to be a powerful, but not pathognomonic, diagnostic tool.

Biliary lithiasis in early pregnancy and abnormal development of facial and distal limb bones (Binder syndrome): A possible role for vitamin K deficiency

BACKGROUND

Binder syndrome is a maxillonasal dysostosis characterized by midface and nasal hypoplasia, sometimes associated with short terminal phalanges of fingers and toes and transient radiological features of chondrodysplasia punctata. Warfarin- or phenytoin-induced vitamin K deficiency during early pregnancy is a well-established etiology for this syndrome, which occurs nevertheless sporadically in most cases.

CASE(S)

We describe here the first case, to our knowledge, of Binder syndrome in a child whose mother presented with biliary lithiasis in early pregnancy. The mother proved to have a decrease in clotting factors II, VII, and X, and in prothrombin time, at 11 weeks of gestation, which was highly suggestive of vitamin K deficiency.

CONCLUSIONS

The biliary lithiasis-induced vitamin K deficiency in early pregnancy is likely to have resulted in Binder syndrome. This observation should prompt physicians to carefully check for vitamin K deficiency in pregnant women presenting with biliary lithiasis, in order to prevent Binder syndrome in the fetus by providing intravenous vitamin K supplementation as soon as possible. Finally, reassuring genetic counseling regarding the genetic risk for future pregnancies is to be provided to the parents.

Desbuquois dysplasia, a reevaluation with abnormal and "normal" hands: radiographic manifestations

Radiological features of 35 patients with the diagnosis of Desbuquois dysplasia were analyzed. The diagnosis of Desbuquois dysplasia was based on the association of specific facial alterations, markedly short stature of prenatal onset, joint laxity, "Swedish key" appearance of the proximal femur, and advanced carpal and tarsal bone age. Patients were divided into two groups, depending on whether or not typical hands with an extra ossification center distal to the second metacarpal and/or a delta phalanx of the thumb were present (group 1, 46%) or absent (group 2, 54%). In this study, beside the "Swedish key" appearance of the proximal femur and advanced carpal and tarsal ossification, we were able to define three additional major radiographic criteria for the diagnosis of Desbuquois dysplasia, including flat acetabular roof, elevated greater trochanter, and proximal fibular overgrowth. Other manifestations included wide metaphyses, flat epiphyses, coxa valga, coronal and sagittal clefts of the vertebrae, wide anterior rib portions, medial deviation of the foot, and enlarged first metatarsal. We conclude that characteristic hand abnormalities are not mandatory for the diagnosis of Desbuquois dysplasia.

New variant of acro-renal field defect

We describe two patients with a new variant of acro-renal field defect. The first was a full-term, small-for-gestational-age female infant who showed preaxial polydactyly of the right hand and horseshoe kidney on abdominal ultrasonographic examination. In addition, there was a single umbilical artery and some mild facial errors of morphogenesis. The second patient, a full-term male infant, had horseshoe kidney and left hand ectrodactyly. Various renal abnormalities have been described in the literature, but there are no reports on horseshoe kidney as part of acro-renal field defect. We suggest that acro-renal field defect should not be regarded as a definitive diagnosis, but only as a starting point for the search for various conditions.

Four cases with hypoplastic thumbs and encephaloceles

We report on four infants with hypoplastic thumbs and occipital encephaloceles. None had either a chromosome abnormality or a family history of any major malformation. The literature and database were searched intensively. No similar cases were reported previously, suggesting that the constellations might represent a new genetic syndrome.

[Melorheostosis: a case review and review of literature]

The authors present a review of the literature and the diagnostic difficulties in a case of melorheostosis in a 6 year old boy. Melorheostosis is characterized by longitudinal foci of subcutaneous sclerosis, limitation of motion in the joints and swelling of the knee and ankle joints. Radiologically numerous foci of hyperostosis similar to wax flowing down a burning candle have been noted.

Genetic study of SOX9 in a case of campomelic dysplasia

Campomelic dysplasia (CD) is a sporadic autosomal dominant syndrome that results in skeletal malformation and developmental abnormalities. Death usually occurs neonatally as a result of respiratory insufficiencies, but life expectancy varies depending on the severity of the phenotype. XY sex reversal is common in CD, and a range of genital defects is observed in males and females. CD is due to mutations in SOX9, a member of the SOX (SRY-related HMG box) gene family. SOX9 is a transcription factor involved in chondrogenesis and sex determination. We present a CD patient with a normal 46,XX karyotype and female phenotype. Single-stranded conformation polymorphism analysis of DNA from this CD patient demonstrated a single-stranded conformation polymorphism shift in the C-terminal region of SOX9. DNA sequencing showed a frameshift mutation resulting from the insertion of a single guanine residue in nucleotide region 1,453-1,456. This insertion mutation creates a mutant SOX9 open reading frame that is 201 nucleotides longer than the normal gene. It has been shown that the C-terminal region of SOX9 is responsible for the transactivating ability of the protein. The frameshift identified here affects approximately half of the protein region needed for full transactivating function. We hypothesize that residual SOX9 function may explain why this patient survived infancy.

Uruguay facio-cardio-musculo-skeletal syndrome: a novel X-linked recessive disorder

We report on three male patients from a single family with a brachyturricephaly, "pugilistic" facial appearance, a muffled voice, cardiomyopathy, muscular hypertrophy, broad hands, wide feet with progressive pes cavus deformities, dislocation of toes, variable congenital hip dislocation, and scoliosis. Three other males in the family, now deceased from cardiac disease, appear to have had the same disorder. The mother of the propositus has milder signs of the syndrome. All affected males are related through the maternal line. These cases represent an apparently previously undescribed X-linked recessive syndrome.

Bone changes in leprosy patients with disabilities/deformities (a clinico-radiological correlation)

One hundred and ten leprosy patients (96 males and 14 females, mean age 45.3 years) with disabilities/deformities were examined radiologically to evaluate bone changes and correlating them with clinical parameters. Most patients (98) had paucibacillary leprosy. The mean duration of leprosy was 7.4 years and that of deformity was 4.1 years. Ten patients presented with reaction. Seventy-five (68.2%) patients had received a full course of antileprosy treatment. The overall prevalence of bone changes was 87.3% (96 patients); specific, non-specific, osteoporotic and facial changes were seen in 44.5%, 75.5%, 38.2% and 9.1% of the patients respectively. Among the specific bone changes, primary periosteitis (28.2%) and "bone cysts" (22.7%) were the more common findings. Among the non-specific bone changes, terminal phalangeal absorption (48.2%), soft tissue changes (44.5%) and concentric absorption (32.7%) were more common. Specific bone changes showed a significant (P < 0.05) increase with lack of or incomplete antileprosy treatment. Non-specific bone changes showed significant correlation (P < 0.05) with increasing duration of disease, lack of or partial treatment and rising disability index. Osteoporotic changes showed a significant relationship with rising disability index.

Bilateral radial ray hypoplasia with multiple epiphyseal dysplasia

We describe a 5-4/12-year-old girl with the unique combination of bilateral radial ray hypoplasia and multiple epiphyseal dysplasia (MED). Radial ray hypoplasia was diagnosed at birth. MED was documented at age 4-3/12 years when she presented with leg pain and short stature and was found to have femoral anteversion and tibial torsion giving rise to severe genu valgum deformity and intoeing. She has no facial anomalies and is developmentally normal. Family history is unremarkable and chromosomal analysis was normal. Investigation of mineral metabolism showed idiopathic hypercalciuria. Surgical lengthening of her severely hypoplastic left radius at age 19 months was successful. Bilateral femoral and tibial osteotomies at age 5-4/12 years corrected her lower limb deformities. This combination of two distinctive but rare skeletal abnormalities may represent a new syndrome.

Gracile bone dysplasia

Gracile bones are a frequent abnormality associated with fetal hypokinesia of any cause. With the exception of thin, undermineralized bones, the chondro-osseous structure is usually normal in these cases. We present a lethal skeletal dysplasia comprising minor anomalies, central nervous system abnormalities, gracile long bones, and abnormal chondro-osseous morphology. In addition to a short, disordered growth plate, the chondrocytes contained dilated loops of rough endoplasmic reticulum, suggesting an abnormality of an extracellular matrix protein. This protein appears to have effects on chondro-osseous and on facial and central nervous system development. We suggest the term "gracile bone dysplasia" to describe this disorder.

Generalized osteoporosis in a patient with oculocutaneous hypopigmentation syndrome (OOCHS), without cerebral defects. A new syndrome?

An 8-year-old male patient presented a unique pattern of congenital anomalies. Prominent findings included a combination of severe osteoporosis and congenital oculocutaneous hypopigmentation. The patient may represent a hitherto undescribed syndrome of unknown etiology.

[Clinical application of three-dimensional spiral CT in skeletal disorders]

Three-dimensional (3D) computed tomographic reformations are used as an adjunct to standard axial computed tomography (CT) in the evaluation of disorders affecting areas of complex anatomy such as the skull, the spine, the pelvis, hands and feet. 3D-CT can provide a clear impression of lesion extent, pattern, shape and proximity to adjacent structures. This unique spatial information potentially has a significant impact on decisions regarding resectability, surgical approach and repair. The basic requirements for high-quality 3D-reformations are an absence of patient movement and narrow-width transaxial sections. Spiral CT significantly contributes to fulfilling these requirements. In addition, spiral CT scan data can be used to produce the ultimate representation of the third dimension: a life-size palpable medical model. In this review we describe the process of three-dimensional reconstruction and highlight potential problems arising during 3D-imaging processing. Useful clinical applications of spiral CT for 3D-visualization of skeletal pathology are discussed.

An 11-year-old boy with swelling and progressive deformity of his finger

The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopaedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on the first two pages. The final clinical and roentgenographic differential diagnoses are presented on the following pages.

Hepatoerythropoietic porphyria in a woman with short stature and deformed hands

A 23-year-old woman from Honduras was diagnosed to have hepatoerythropoietic porphyria. She had photosensitive skin of early onset, hypertrichosis, and severe scleroderma-like lesions of the hands. Erythrocyte uroporphyrinogen decarboxylase activity was reduced to about 10% of the normal activity.

Skeletal dysplasia syndrome with progeroid appearance, characteristic facial and limb anomalies, multiple synostoses, and distinct skeletal changes: a variant example of the Lenz-Majewski syndrome

Here we report a 10 year-old mentally retarded, deaf boy with a unique pattern of anomalies: progeroid appearance, characteristic facial and limb anomalies, multiple synostoses, and distinct skeletal changes. He represents a variant example of "hyperostotic dwarfism" as delineated by Lenz and Majewski.