Pediatric Musculoskeletal (MSK) X-ray OSCE

1. Scurvy
2. Rickets
3. Osteopetrosis
4. Gaucher's Disease
5. Hypothyroidism
6. Congenital Syphilis
7. Lead poisoning

Masculoskeletal X-ray finidngs in Scurvey

Overview of skeletal signs in Scurvy

Pelken's spur

1. The shaft of long bones
2. Epiphyseal centers of ossifications.

Reason for GGO in Scurvy

Trabecular destruction and Atrophy of the trebeculae result in GGO. These are peculiarly noted arround knee joint.

Thin and dense Cortical bones. (diphyseal finding)

Irregular but thickened white line at metaphysis in X-ray which represents zone of well calcified cartilage.

Remember these are seen in active scurvy and first radiological sign treatment of rickets

Sclerotic ring of increased density around epiphysis.

Zone of rarefaction under white line of metaphysis ( More specific). It is adjacent to frankel line.

The area represent debris of broken down bone trabeculae and connective tissue. It is also known as the scurvy line

Lateral prolongation of white line present at cortical end.

In advance disease the x-ray additionally shows Sub-periosteal haemorrhages with calcification

Rickets

Image.3 - Signs in rickets

Image.4 - Notice Generalised rerefaction: source 3

1. Thickening of growth plate due to reduced calcification.
2. Fraying - Due to weight-bearing the The edge of metaphysis looses its sharp border and becomes irregular
3. Splaying- Due to weight-bearing, the metaphysis starts spreading out called as splaying.
4. Cupping - Convex or flat edge of metaphysis changes to concave surface.
5. Widening of distal end of metaphysis ( Growth plate)
6. Generalised rerefaction

Rickets	Scurvy
white line of Frankel is a sign of healing Rickets	white line of Frankel is sign of disease
The rachitic rosary is non-tender	Scorbutic rosary is tender
Radiologically allegedly more severe changes in upper extremities	Radiologically more severe changes in lower extremities.

Osteopetrosis

Fig.5 - Compare the densities of these two bones

Fig.6 - Notice Sandwich like appearance of vertebral bones

1. Generalized increase in bone density and clubbing of metaphysis.
2. Called a marble bone due to increased density. ( more white/opaque)
3. Erlenmeyer flask deformity ( read below in Gaucher's disease)
4. Alternating dense and lucent bands produce a sandwich appearance to vertebral bodies.
5. Bone-in Bone appearance.

Note that the more dense long bones are actually brittle and prone to recurrent pathological fractures

The term is used to describe bones that appear to have another bone within them. The differentials for bone-in bone appearance are

1. Normal thoracic and lumbar vertebrae in neonates.
2. Artifact.
3. sickle cell disease/ thalassaemia /Gaucher disease
4. chronic osteomyelitis
5. scurvy
6. Caffey disease
7. osteopetrosis
8. Lead poisoning
9. Hypervitaminosis D
10. leukaemia, metastases

Gauchers disease

1. Bone is bone appearance.
2. Erlenmeyer flask deformity.

Fig.7 - Erlenmeyer flask deformity

Erlenmeyer flask deformity is not specific for Gaucher disease.

The sign is described as reduced constriction of the diaphysis and flaring of the metaphysis as a result of undertubulation.

Described classically in femoral bones and looks like a flat bottom flask used in chemistry.

It also means that the pathology occurred in the developing skeleton.

1. Gaucher disease
2. Niemann-Pick disease (type B)
3. Thalassaemia -especially if treated with desferoxamine.
4. Sickle cell disease
5. Chronic lead poisoning
6. Osteopetrosis
7. Achondroplasia

Hypothyroidism

1. Retardation of osseous development.
2. Absence of distal femoral and proximal tibial epiphysis.
3. Epiphysis often has multiple foci of ossification called as epiphyseal dysgenesis.
4. Spine x-ray - Breaking of 12th and or 1st/2nd lumbar vertebrae
5. Skull x-ray
   1. Large Fontanels
   2. Wide sutures
   3. wormian bones - Intersutural bones.
   4. Sella turcica -looks enlarged and round.
6. Chest Xray
   1. Cardiac enlargement
   2. Pericardial effusion

Lead Poisoning

1. Chronic lead poisoning shows lead lines in growing bones.
2. They are not an early manifestation of toxic lead exposure.
3. Lead lines usually occur at a blood level of more than 70-80 mcg/dL

Bands of increased density (opaque) at metaphysis of tubular bones which are growing. They are Seen commonly in the proximal fibula and distal ulna.

Growth is not as great as other long bones here.

Note that Burton’s line is a blue-purplish line on the gums seen in also chronic lead poisoning. It is caused by a reaction between circulating lead with sulfur ions released by oral bacterial activity, which deposits lead sulfide at the junction of the teeth and gums.

Congenital Syphilis

1. It is pathognomic of congenital syphilis.
2. Caused by Bilateral Metaphyseal demineralization of medial aspect of the proximal tibia.

Do not confuse with the Wimberger ring sign.

1. Multiple sites of osteochondritis in the wrist, elbow, ankles, and knees, etc.
2. Periostitis of long bones.

Further Reading

1. Musculoskeletal X-ray - General principles
2. Musculoskeletal X‐rays for Medical Students and Trainees 2017 Pdf book

Related Post :

1. Chest X ray interpretation in Pediatric OSCE exam
2. Pediatric OSCE Stations - Radiology
3. Chest X ray interpretation in Pediatric OSCE exam

Atrributions

1. Source 1- Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 19946
2. Source 2- Hussein A. Algahtani,a Abduljaleel P. Abdu,a Imad M. Khojah,b and Ali M. Al-Khathaamic, CC BY 2.5, via Wikimedia Commons
3. Source 3- Frank Gaillard, CC BY-SA 3.0, via Wikimedia Commons

Author

Shama Sowdagar | DNB (Pediatrics)

Shama has completed residency from Kanchi kamakoti Child Trust Hospital, Chennai and works as a Pediatrician