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Normal Developmental Variants Confused With Disease
A. Carlson Merrow, Jr., MD, FAAP
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KEY FACTS

  • Imaging

    • Top Differential Diagnoses

      • Clinical Issues

        • Diagnostic Checklist

          TERMINOLOGY

          • Definitions

            • Skeletally immature patients have numerous radiolucent growth centers composed of cartilage
              • Primary physis: Site of majority of longitudinal growth; lies between epiphysis & metaphysis
              • Secondary physis: Surrounds secondary ossification center (SOC) in epiphysis or equivalent bone
                • Interface where cartilaginous precursor is transformed into bone from central to peripheral
                • Process is uniform in some centers (capitellum, femoral head), nonuniform in others (fragmented trochlea, irregular medial femoral condyle)
              • Apophysis: Nonarticular SOC with muscle/tendon attachment (ischial & tibial tuberosities)
              • Zone of provisional calcification (ZPC): Thin, radiodense line at interface of physeal growth cartilage & newly mineralized bone
            • Accessory ossification centers: Separate small rounded ossicles vs. SOCs in same unossified cartilage as adjacent epiphysis or equivalent
            • Pseudoepiphysis: False appearance of growth centers at distal 1st & proximal 2nd-5th metatarsals & metacarpals
            • Physiologic periosteal reaction (PPR): Smooth, solid, new bone being laid down rapidly along entire lengths of long bone diaphyses in infants

          IMAGING

          • General Features

            • Radiographic Findings

              • MR Findings

                • Imaging Recommendations

                  DIFFERENTIAL DIAGNOSIS

                    CLINICAL ISSUES

                    • Presentation

                      DIAGNOSTIC CHECKLIST

                      • Image Interpretation Pearls

                        Selected References

                        1. Berko NS et al: Imaging appearances of musculoskeletal developmental variants in the pediatric population. Curr Probl Diagn Radiol. 44(1):88-104, 2015
                        2. Oestreich AE: Concave distal end of ulna metaphysis alone is not a sign of rickets. Pediatr Radiol. 45(7):998-1000, 2015
                        3. Zbojniewicz AM et al: Imaging of osteochondritis dissecans. Clin Sports Med. 33(2):221-50, 2014
                        4. Kan JH et al: Embryology, anatomy, and normal findings. In: Caffey's Pediatric Diagnostic Imaging, 12th ed. Philadelphia: Elsevier Saunders. 1327-46, 2013
                        5. Laor T et al: Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? AJR Am J Roentgenol. 199(5):1121-8, 2012
                        6. Varich LJ et al: Normal maturation of the distal femoral epiphyseal cartilage: age-related changes at MR imaging. Radiology. 214(3):705-9, 2000
                        7. Laor T et al: Musculoskeletal system. In Kirks DR: Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia: Lippincott-Raven. 327-510, 1998
                        Related Anatomy
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                        Related Differential Diagnoses
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                        References
                        Tables

                        Tables

                        KEY FACTS

                        • Imaging

                          • Top Differential Diagnoses

                            • Clinical Issues

                              • Diagnostic Checklist

                                TERMINOLOGY

                                • Definitions

                                  • Skeletally immature patients have numerous radiolucent growth centers composed of cartilage
                                    • Primary physis: Site of majority of longitudinal growth; lies between epiphysis & metaphysis
                                    • Secondary physis: Surrounds secondary ossification center (SOC) in epiphysis or equivalent bone
                                      • Interface where cartilaginous precursor is transformed into bone from central to peripheral
                                      • Process is uniform in some centers (capitellum, femoral head), nonuniform in others (fragmented trochlea, irregular medial femoral condyle)
                                    • Apophysis: Nonarticular SOC with muscle/tendon attachment (ischial & tibial tuberosities)
                                    • Zone of provisional calcification (ZPC): Thin, radiodense line at interface of physeal growth cartilage & newly mineralized bone
                                  • Accessory ossification centers: Separate small rounded ossicles vs. SOCs in same unossified cartilage as adjacent epiphysis or equivalent
                                  • Pseudoepiphysis: False appearance of growth centers at distal 1st & proximal 2nd-5th metatarsals & metacarpals
                                  • Physiologic periosteal reaction (PPR): Smooth, solid, new bone being laid down rapidly along entire lengths of long bone diaphyses in infants

                                IMAGING

                                • General Features

                                  • Radiographic Findings

                                    • MR Findings

                                      • Imaging Recommendations

                                        DIFFERENTIAL DIAGNOSIS

                                          CLINICAL ISSUES

                                          • Presentation

                                            DIAGNOSTIC CHECKLIST

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Berko NS et al: Imaging appearances of musculoskeletal developmental variants in the pediatric population. Curr Probl Diagn Radiol. 44(1):88-104, 2015
                                              2. Oestreich AE: Concave distal end of ulna metaphysis alone is not a sign of rickets. Pediatr Radiol. 45(7):998-1000, 2015
                                              3. Zbojniewicz AM et al: Imaging of osteochondritis dissecans. Clin Sports Med. 33(2):221-50, 2014
                                              4. Kan JH et al: Embryology, anatomy, and normal findings. In: Caffey's Pediatric Diagnostic Imaging, 12th ed. Philadelphia: Elsevier Saunders. 1327-46, 2013
                                              5. Laor T et al: Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? AJR Am J Roentgenol. 199(5):1121-8, 2012
                                              6. Varich LJ et al: Normal maturation of the distal femoral epiphyseal cartilage: age-related changes at MR imaging. Radiology. 214(3):705-9, 2000
                                              7. Laor T et al: Musculoskeletal system. In Kirks DR: Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia: Lippincott-Raven. 327-510, 1998