Normal Variants, Congenital and Acquired Disorders
Although in the differential diagnosis of fractures sustained in childhood one should be particularly aware of accidental trauma, it was found that congenital and acquired defects regularly give rise to suspicions of child abuse (see Table 7.1). Based on
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Normal Variants, Congenital and Acquired Disorders
7.1 Introduction Although in the differential diagnosis of fractures sustained in childhood one should be particularly aware of accidental trauma, it was found that congenital and acquired defects regularly give rise to suspicions of child abuse (see Table 7.1). Based on a combination of patient history, laboratory tests and radiological examination, it is usually possible to reach the correct diagnosis. In this chapter we discuss the most important disorders of which the radiological images could fit the criteria for child abuse.
7.2 Normal Variants When evaluating radiographs of children, there are a number of normal variants that may cause confusion, and even lead to a false accusation of child abuse. At a very young age, subperiosteal new-bone formation around the shaft of the femur, tibia and humerus may be seen in normal, healthy neonates and infants (Fig. 7.1). This newly formed bone, which may radiologically be mistaken for a healing fracture, is most prominently present in children from 1 to 6 months old. Subperiosteal newly formed bone is usually seen bilaterally [1]; however, it may be more prominently present unilaterally [2]. Generally, the most distinct signs will disappear around the age of 8 months [3]. In physiological, subperiosteal newly formed bone, there is no obvious uptake of isotopes in a bone scan [4]. Neither should normal metaphyseal variants be mistaken for child abuse. This category comprises thickened edges of the metaphyses (collar, step off) exactly where the epiphyseal plate is attached (Fig. 7.2a–c).
This collar is usually present in the proximal tibia, proximal fibula, distal femur, distal radius and distal ulna, and is regularly seen bilaterally [5]. In young children pointed metaphyseal ‘spurs’ can also be found, which to the untrained eye of a radiologist may look very similar to CMLs. This spur is made of cortical bone that grows under the perichondrial ring of the epiphyseal plate. Spurs may be seen in the distal femur (Figs. 7.1 and 7.2b), the lateral aspect of the distal radius, the medial aspect of the distal ulna and the metacarpals (Fig. 7.3) and metatarsals. In 25% of cases this image is seen bilaterally. Finally, the metaphysis may show medial widening, especially in the proximal tibia and the humerus (Fig. 7.4). In 4% of children a cortical irregularity is seen on the medial side of the proximal tibia. In 25% of these children this is present in both legs [5]. This irregularity may look like a healing fracture and consequently lead to an incorrect diagnosis. One of the most important properties of the childhood skeleton is growth. Besides the normal growth centers, accessory centers may be seen (Fig. 7.5a and b) [6], which may be interpreted erroneously as fractures, and as such lead to confusion. The sutures of the skull, where normal variants may be found (Fig. 7.6), may also lead to an erroneous diagnosis of skull fracture [7].
7.3 Osteogenesis Imperfecta 7.3.1 Introduction Together with child abuse osteo
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