7 Skeleton. Anatomy. Long Bones

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1 7 Skeleton The second most frequent rdiogrphic study, fter the chest film, is tht of the peditric skeleton. The most common indiction for such studies is of course trum. In order to understnd the disese processes tht occur in the peditric ge group one must first know the skeletl ntomy. The skull nd spine re covered in Chp. 8. Antomy Long Bones The two physiologicl mechnisms of one production nd development re endochondrl (long ones) nd intrmemrnous ossifiction (flt ones). The long one of child is divided into four res (Fig. 7.1): Diphysis: the shft of the long one Metphysis: from the re where the one widens to the physis Physis: the lucent line where growth tkes plce prior to clcifiction of the crtilge Epiphysis, or secondry ossifiction center: portion of which interfces with the joint s the rticulr crtilge nd llows movement within the joint The center of the long one is the medullry cvity, while the outer one is clled the cortex. Some long ones (e.g., the femur) hve nonrticulting pophysis (see Fig. 7.1), which is similr to the epiphysis ut does not contriute to the length of the one (e.g., the greter trochnter of the femur). In the growing child s skeleton, lood supply is primrily to Fig The norml femur Schemtic drwing of norml femur Rdiogrph of norml femur

2 170 7 Skeleton the metphysis, nd mny of the disese processes nd roentgen findings re seen in this region. For exmple, hemtogenous osteomyelitis is visile most often in the metphysis; similrly, metstses trvel hemtogenously to the metphysis. Flt Bones In contrst to long ones, flt or memrnous ones do not hve single growth plte ut rther mesenchyml network or memrne tht ttrcts osteolsts, which form osteoid. There re equivlent diphysel, metphysel, nd epiphysel res, however, which ehve very similrly to their counterprts in the ppendiculr skeleton. Memrnous ones include the mndile, pelvis, scpul, se of the skull, the clvicles, nd the sternum. Unique Fetures The skeleton of children is quite different from tht of dults. The child s ones re oviously still growing, developing, nd modeling; therefore, mny ossifiction centers re constntly ppering nd fusing with the min skeleton (Fig. 7.2) (Tle 7.1). Becuse these ossifiction centers my pper frgmented nd my ossify in multicentric fshion, they cn esily simulte chip frctures. One should therefore otin comprison views of the contrlterl extremity if there is ny question. Insults from infection, tumor, or trum to the metphysel region, physis, nd epiphysis re much more dmging in children thn in dults ecuse the growth plte is distured. Frctures involving the growth plte re clled Slter Hrris frctures nd crry prognostic rting ccording to the severity of the growth plte injury (I V, with V eing the worst; Fig. 7.3). Severe length discrepncies nd other growth disturnces cn occur from frctures in these regions. Another unique difference etween the child s nd the dult s skeleton is the low incidence of disloctions (complete disruption of the joints with loss of contct etween rticulting surfces) of otherwise norml joints. Becuse children s cpsulr nd ligmentous structures re two to five times stronger thn the wekest prt of the growth plte, the growth plte frctures first, nd disloction occurs less frequently. The zone of clcifying crtilge (Fig. 7.4) is the wekest portion of the growth plte. The growing Tle 7.1. Approximte ge of ossifiction of secondry centers in elow Center Cpitellum 1 Rdil hed 4 Inner (medil) epicondyle 7 Trochle 10 Olecrnon 10 Externl (lterl) epicondyle 11 Age (yers) ones of children re lso unique in tht they re more plstic nd more likely to end efore they frcture (Fig. 7.5). Becuse of this resiliency children re more likely to hve incomplete frctures, two of which hve chrcteristic nmes the greenstick frcture nd the torus frcture. The greenstick frcture is chrcterized y owed long one with rek on the convex surfce ut pprent corticl continuity on the concve surfce. In the torus frcture there is uckling on one side of the cortex (see Fig. 7.5). In oth of these frctures, however, microscopic exmintion shows nondisplced frctures of osteoid cross the one. In children the periosteum is constntly growing. Therefore it is less firmly ttched to the diphysis, or shft, of the long one nd is more likely to ter nd thus e elevted y trum nd hemtom formtion. The periosteum rects y lying down thick lyer of new one. In contrst, the periosteum t the ends of the long ones is not loosely ttched ut rther firmly dherent to the metphysel regions. Twisting injuries here cuse vulsion of piece of one from the metphysis. This type of ucket-hndle injury or vulsion corner frcture is commonly found in cses of child use (Fig. 7.6; discussed elow). Another difference etween the dult nd child is the ility to estimte one mturtion in those in the peditric ge rnge (discussed elow, Bone Age Determintion ).

3 Unique Fetures 171 c Fig The norml elow t different stges of development Note the ppernce of the vrious ossifiction centers s the child mtures (see Tle 7.1) A 6-month-old. Cpitellum (C) is ossified A 4-yer-old. Rdil hed (rrow) nd medil epicondyle (sterisk) hve egun to ossify c An 8-yer-old. Secondry centers of ossifiction re lrger d A 15-yer-old. Mture elow with closure of the growth pltes d

4 172 7 Skeleton Fig Slter-Hrris frctures Slter Hrris clssifiction of frctures involving the growth plte. Prognosis depends on integrity of the lood supply nd frcture type. Slter IV nd V hve worse prognosis thn I, II, nd III Slter II frcture of the proximl phlnx of the thum. The frcture involves the metphysis nd physis Fig Photomicrogrph showing different zones of the growth plte Shering forces pplied to the growth plte result in frcture through the zone of clcifying crtilge. (From [1] with permission)

5 Unique Fetures 173 Fig Common peditric frctures Greenstick frcture. The frcture ppers to extend hlfwy through the diphysis (rrow). Note the owing of the rdius nd uln Torus frcture. Note the uckling t the medil spect of the distl rdius (rrow). Microscopic exmintion of oth greenstick nd torus frctures show treculr disruption cross the entire horizontl width of the one Fig Bucket-hndle frctures Drwings of metphysel frcture s it ppers with vrious rdiogrphic projections nd distrctions Bucket-hndle frcture of distl femur. A thin vulsion of one t the femorl metphysis (rrow) resemles the resting hndle of ucket. This frcture is commonly seen in the ttered child syndrome c Another child with profuse periostel rection out the distl femur nd proximl tii. This defines the ucket-hndle lesions c

6 174 7 Skeleton Imging Modlities in Evluting Musculoskeletl Disese Plin Film Rdiogrphy The plin film is the initil exm performed in the vst mjority of cses of suspected musculoskeletl pthology. Although plin film rdiogrphy is not the most sensitive imging exm for musculoskeletl pthology, it is redily ville, inexpensive, nd provides sufficient dignostic informtion for most prolems, including one tumors. Tle 7.2. Indictions for one ge determintion Short stture Tll stture Precocious puerty Delyed puerty Timing of orthopedic surgery (e.g., correction of lim length discrepncy, scoliosis) Bone Age Determintion Plin rdiogrphs re used to ssess skeletl mturity. A child s one ge needs to e determined in severl clinicl situtions (Tle 7.2). For children over the ge of 1 yer, most endocrinologists nd rdiologists do this y compring PA view of the child s left hnd with the stndrds in the Greulich Pyle Rdiogrphic tls of skeletl development of the hnd nd wrist [2]. The tls includes stndrds for mles nd femles s well s the stndrd devitions in skeletl ge t different chronologic ges. One should keep severl importnt points in mind when determining one ge: 1. The stndrds in the Greulich Pyle tls re sed on the hnd rdiogrphs of norml white Americn children. How vlid the tls is for children of other rces or ethnicities is not cler, nd clinicins must tke this into ccount. One should tret the one ge like growth nd development curves. 2. Phlngel ge is more ccurte thn crpl ge. 3. Phlngel ge is ssessed y presence, reltive width, shpe, nd fusion of vrious phlngel epiphysel ossifiction centers (see Fig. 7.7) 4. For the one ge to e considered norml, it should lie within two stndrd devitions from the ptient s chronologic ge. 5. In children under 1 yer of ge, one ge is usully determined y the Sontg method of totling the numer of visulized ossifiction centers (Tle 7.3) in one side of the skeleton nd compring it with stndrd tle (Tle 7.4). Fig Bone ge This mle ged 13 yers, 5 months hs delyed puerty. His left hnd rdiogrph most closely resemles the Greulich Pyle stndrd for mle of 11 yers, 6 months. The stndrd devition for 13-yer-old mle s given in the Greulich Pyle tls s 10 months. Therefore, his one ge is delyed (greter thn two stndrd devitions elow his chronologic ge)

7 Plin Film Rdiogrphy 175 Tle 7.3. List of ossifiction centers (totl: 67). (From [3] with permission) Shoulder Corcoid Humerus Proximl medil epiphysis Proximl lterl epiphysis Cpitellum Medil epicondyle Rdius Proximl epiphysis Distl epiphysis Hnd Cpittum Hmtum Triquetrum Lunte Nviculr Greter multngulr one Lesser multngulr one 5 distl phlngel epiphyses 4 middle phlngel epiphyses 5 proximl phlngel epiphyses 5 metcrpl epiphyses Femur Proximl epiphysis Greter trochnter Distl epiphysis Knee Ptell Tii Proximl epiphysis Distl epiphysis Fiul Proximl epiphysis Distl epiphysis Foot Cuiod First cuneiform Second cuneiform Third cuneiform Nviculr Epiphysis of clcneus 5 distl phlngel epiphyses 4 middle phlngel epiphyses 5 proximl phlngel epiphyses 5 mettrsl epiphyses Tle 7.4. Men totl numer of centers on the left side of the ody ossified t the given ges. (From [3] with permission) Boys Girls Age (months) Men no. SD Men no. SD

8 176 7 Skeleton, c Fig CT of nkle reformtted in coronl () nd sgittl () nd the exmined xil plne (c) show the juvenile Tilluxtype frcture nd the ntomy of the distl tiil rticulr surfce more clerly thn the corresponding plin rdiogrphs (see Fig. 7.13). There is frcture through the epiphysis (rrow) nd lso through the physel plte (firocrtilge), mking this Slter Hrris type III frcture Computed Tomogrphy CT cn define osseous ntomy in more detil thn the plin film, with greter definition of oth the corticl one nd the medullry cvity. This is prticulrly vlule in confirming rdiogrphiclly sutle frctures, dignosing nd loclizing suspected osseous normlities (e.g., sequestrum, one- or clcium-producing lesion, etc.), nd evluting difficult res (e.g., scrum, sternum, scpul, ones in cst). CT imges cn e reformtted in vrious plnes nd reconstructed to three-dimensionl imges. This helps orthopedic surgeons in preopertive plnning (Fig. 7.8). Mgnetic Resonnce Imging MR demonstrtes the one mrrow, joints, crtilge nd soft tissues in exquisite detil (Fig. 7.9), nd is therefore very sensitive in detection of the extent of pthology involving these structures. Specificlly, MR is frequently used in evlution of ligmentous nd crtilginous injuries, joint pthology, soft tissue tumors, musculoskeletl infection, nd vsculr necrosis. It does not show detil of corticl one or clcifiction s well s CT. Other disdvntges of MR include its expense, the frequent need for sedtion in younger ptients, nd limited vilility. It is lwys est to interpret MR scns in correltion with the plin films. Nucler Medicine Most nucler medicine imging of one is performed y injecting the ptient with phosphte compound leled with the rdioisotope technetium 99m. Over the next 2 h, the phosphte is incorported into one. The extent to which this incorportion occurs in different prts of the skeleton is determined y lood flow nd y one turnover. When the ptient is imged under gmm cmer, the distriution of rdiophrmceuticl in the skeleton is shown (Fig. 7.10). Ares of normlity usully show incresed ctivity reltive to the reminder of the skeleton. Nucler medicine one scn is useful in evluting diffuse processes (e.g., metsttic neoplsm), in detecting res of normlity tht hve not ecome rdiogrphiclly visile (e.g., erly osteomyelitis), nd in loclizing res of pthology for more trgeted imging with CT or MR (e.g., ck pin). Bone scn imging nd interprettion cn e difficult. Becuse the ptients must remin sufficiently still for the gmm cmer to mesure the rdioctivity from the skeleton, younger children need to e sedted for this exm. The technologists must py prticulr detil to ptient positioning nd proper imge cquisition. Nucler medicine studies do not provide the ntomic detil tht CT, MR, nd plin rdiogrphy do, nd so one scns need to e interpreted in correltion with plin films.

9 Nucler Medicine 177 c Fig MR of the norml knee Sgittl proton density view shows menisci of firocrtilge (m) nd rticulr (hyline) crtilge (rrow) Sgittl proton density view revels norml nterior crucite ligment (AC) nd qudriceps (Q) nd ptellr (P) tendons c Coronl T1-weighted view of the tiil spine (TS), meniscus (rrow) nd collterl ligments. M, medil; L, lterl d Sgittl ft-sturted spoiled grdient imge is est for evluting the rticulr (hyline) crtilge (rrow) d

10 178 7 Skeleton Fig Imges from norml whole ody one scn in child Note tht there is reltively more ctivity in the metphyses ecuse of the greter lood supply to these zones of growth. The right rm (rrow) ws the site of injection Fig Longitudinl sonogrphic view of norml infnt hip: the crtilginous femorl hed (F) is positioned in the cetulum. I, ilium Ultrsound As rule, ultrsound is not very helpful in evluting introsseous pthology, since one is not good conductor of sound. However, ultrsound cn e useful in evluting crtilginous ntomy (e.g., the nonossified femorl hed in n infnt with developmentl hip dysplsi; Fig. 7.11), dignosing joint effusion, detecting nonopque soft tissue foreign odies, nd evluting soft tissue msses nd synovil hypertrophy. In some centers, ultrsound is even used to evlute tendons nd ligments, lthough this is more frequently done with MR. Generl Approch to the Skeletl Plin Film Before eginning to evlute ny imges, the rdiologist must know few importnt clinicl fcts, such s the ptient s ge, sex, rce, prior tretment, nd whether this is generlized or locl one disturnce. With this informtion, the rdiologist cn mke intelligent decisions out the child s rdiogrphs, s explined elow. Age. As discussed in the work-up of child with n dominl mss, the tendency of lesions to occur t different ges helps one to form the differentil dignosis. For exmple, 6-yer-old is more likely to hve septic necrosis of the cpitl femorl epiphysis (Legg-Clvé-Perthes disese), while hip disese in teenger is often slipped cpitl femorl epiphysis. Sex. Hemophili ffects only mles; therefore it follows tht rthropthy nd one chnges re found only in mles.

11 Generl Approch to the Skeletl Plin Film 179 Rce. Sickle cell nemi, Gucher s disese, nd thlssemi re importnt considertions in different rcil nd ethnic ckgrounds sickle cell disese in lck children, Gucher s disese in Jewish children, nd thlssemi in children of Mediterrnen ncestry. Prior Tretment. It is importnt for the rdiologist to know whether the lesion hs lredy een prtilly treted, since it my disply very different roentgenogrphic ppernce in the treted stte. For exmple, heling or treted one cyst ppers much different thn the untreted vriety. Generlized or Locl Disese. Finlly, the rdiologist must know whether this is the only one involved, or whether the disese ffects multiple ones. Lngerhns cell histiocytosis, firous dysplsi, nd metstses re systemic one diseses, while simple one cysts nd Brodie s scess re most commonly isolted focl disorders (Fig. 7.12). A skeletl survey or one scn frequently is helpful in working up systemic disorders. Before dignosing specific ony normlities it is importnt to evlute exposure. Is the film overexposed? This cn e judged y looking t the soft tissues nd seeing whether they re urnt out or clerly visile. If they re not clerly visile, the film is overexposed. If the ones re so light tht the treculr pttern is indistinct or invisile, the film is underexposed. Improperly exposed digitl rdiogrphs my e postprocessed to show dequte one nd soft tissue detil, ut the rdition dose cnnot e determined y the finl product. It is importnt to look t the exposure fctors on ll films. Fig Metstsis Creful ttention to the texture of the one shows res of lucency (lck) nd sclerosis (white). These correspond to lytic nd lstic lesions cused y medullolstom tht metstsized to one. While lytic metstses re commonly seen, lstic ones re quite infrequent It is lso importnt to look t ny ony normlity in two or more views. Frctures re esily missed if one relies on only single view of the re. Comprison views re frequently necessry. We use the sme ABCS system to evlute skeletl rdiogrphs tht we use to evlute chest rdiogrphs: A=domen (ny prt of the domen on the film is exmined), B=ones (sve for lst; see elow), C=chest (ny prt of the chest on the film is exmined), S=soft tissues (give clues to the site nd kind of injury, Tle 7.5, Fig. 7.13). Tle 7.5. Anormlities of soft tissue. (Modified from [4] with permission) Wht to look for Soft tissue swelling Ft-pd elevtion Muscle wsting Clcifictions Opque foreign odies Gs in tissue plnes Adjcent surprises Disese Most likely site of one normlity. Cn e hemorrhge, trumtic edem, inflmmtion or neoplstic normlity Fluid within joint displcing the perirticulr ft Disuse, neuromusculr normlity, chronic disese of ny etiology requiring lots of immoiliztion Old trum; hemngioms; metolic, prsitic or connective tissue disorders (dermtomyositis, scleroderm) Glss (even nonleded glss) is often visile on rdiogrph Penetrting trum, infection y gs-forming cteri Unsuspected renl or ppendicel clculi, especilly on lumr spine films

12 180 7 Skeleton Fig Osteomyelitis The uln, rdius, nd humerus ll exhiit smooth periostel rection (rrows). The rdius hs lytic defect t its distl position. This child hs sickle cell disese with multifocl osteomyelitis Fig Soft tissue swelling nd frcture There is extensive soft tissue swelling over the lterl mlleolus (rrowheds) ssocited with the ptient s distl tiil frcture of the physis nd through epiphysis (rrows) (see Fig. 7.8) In evlution of the ones themselves, we use nother ABC system [5]: A=lignment; B=one size, shpe, texture, minerliztion, nd mturtion; C=crtilge nd joint spce. Alignment of Bones. Disruption of one cortex nd rticulr surfces is esy to spot when you look for it! Rule No. 14: When viewing n extremity, try to imgine the ppernce of the ptient. An excellent exmple is owed legs or knock knees. Bone Size, Shpe,Texture, Minerliztion, nd Mturtion. The configurtion of the one nd its specil reltionship helps determine the presence of frctures, disloctions, or congenitl nomlies. Mny norml nd norml findings cn e detected y looking t the one surfce the cortex. Periostel rection, with the exception of so-clled physiologicl ppositionl new one found symmetriclly in infnts 2 6 months of ge (see elow), should e regrded s norml. Rememer, periosteum is normlly not visile. It is seen only when it hs een stimulted to ly down new one, or the one eneth it hs een resored (Tle 7.6). With n osteomyelitic process one cn see corticl destruction long with reprtive periostel new one (Fig. 7.14). Tle 7.6. Cuses of periostel rection Infection: osteomyelitis (includes congenitl syphilis) Trum: nonccidentl injury, heling frcture Metolic: rickets, scurvy Tumors/tumor-like diseses: osteosrcom, Ewing s srcom, histiocytosis Idiopthic: Cffey s disese Itrogenic/toxic: prostglndin, hypervitminosis A Rule No. 15: The periosteum is normlly not seen. Next we look t the texture of the one with its normlly uniform treculr pttern nd uniform minerliztion. We dignose metsttic disese nd infection y the permetive destructive nture of one involvement (see Fig. 7.12). These lesions do not hve well-defined mrgins. At this time we cn lso detect metolic disorders such s rickets nd scurvy (Fig. 7.15). The medullry cvity is nother impor-

13 Generl Approch to the Skeletl Plin Film 181 Fig Rickets In young child the ones re deminerlized nd frctured. The distl rdil nd ulnr metphysis re indistinct, fryed, nd cupped In n older child, note how fr the distl epiphysis is from the metphysis Fig Vcuum phenomenon Lucent (lck) line outlines the crtilginous hed of the femur (rrows). This lucency, often seen in the lrge joints of children, is cused y pulling, resulting in vcuum in the joint tht llows nitrogen to enter nd outline the rticulr crtilge of the one Similr lucency outlines the humerl hed (rrow)

14 182 7 Skeleton tnt component to evlute. The mjor component of the medullry cvity the one mrrow is not seen on plin films ut is seen extrordinrily well on MR (see elow). Bone mturtion (see ove) ecomes importnt when suspecting certin diseses such s hypothyroidism, where the one ge is mrkedly decresed. Crtilge nd Joint Spce. Rememer, one does not see the joint spce lone on plin films rther the nonclcified rticulr crtilge nd joint spce re viewed together (Fig. 7.16). Since only smll portion of this region is joint spce, ny nrrowing my well e significnt. The joint spce should e symmetric nd smooth without ny clcifictions or disruptions (see Fig. 7.16). The crtilge nd joint spce re superly visulized y MR (see elow). Common Peditric Prolems Trum Since trum is the most frequent indiction for skeletl exmintions, it is importnt to know the norml vrints tht my pper. Two excellent sources of norml vrints re found in the ooks of Kets [6] nd Köhler [7]. It is importnt to compre oth sides when one is in dout out the presence of frcture (Fig. 7.17). Let us strt y looking t the fetus, which is rrely trumtized ecuse it is in protected environment n mniotic fluid wter th. Frctures, however, my occur in congenitl diseses such s osteogenesis imperfect. This disese is chrcterized y multiple prtil nd complete frctures in mny ones (Fig. 7.18). During difficult deliveries, such s reech presenttions, frctures my e sustined; the most common ones involve the clvicles nd skull. Since the infnt is not very moile during the first yer of life, most injuries nd frctures re secondry to vrious kinds of ccidents. Prticulr findings, however, led the rdiologist to suspect child use (discussed elow under Nonccidentl Injury ). When it is necessry to determine the ge of frcture, rememer: the younger the child, the fster the heling. In ll children, however, the initil reprtive process periostel rection egins 7 14 dys fter the originl injury. One must not, however, confuse the norml ppositionl new one formtion in infnts from 2 to 6 Fig Importnce of fmilirity with norml skeletl ntomy nd symmetry The orienttion of the norml pophysis (rrow) is prllel to the longitudinl xis of the fifth mettrsl one Compre this to the frcture line t the se of the fifth mettrsl (rrow), which is oriented perpendiculr to the one months of ge with pthologicl periostel elevtion. Rther, this is, s previously stted, norml periostel one deposition. It is ilterlly symmetric nd found in the humeri, femor, nd tiie nd extends to the metphysis ut no further. These re not frctures, nor do they denote ny trum (Fig. 7.19). During the reding of children s rdiogrphs we hve found it useful to keep in mind the following trum tips fctors unique to peditrics: The clvicle is prone to greenstick frctures, which my e hrd to visulize. One must tke films in t lest two views to mke sure the child does not hve frcture. The elow hs so mny secondry ossifiction centers tht ossify t different ges tht it is frequently necessry to view the opposite elow for comprison (see Tle 7.1). The supermrket elow usully results from sudden pull on child s rm, s prent is rushing through his/her shopping. If the rdius is dislocted, the child will not move the rm (Fig. 7.20).

15 Trum 183 Fig Osteogenesis imperfect This neworn shows owed nd frctured lower extremities. Note the crinkling of the left femur. These frctures occurred in utero nd resulted from unusully frgile ones due to congenitl defect in collgen rchitecture Fig Appositionl new one formtion This frontl view of 2-month-old child shows wht could e mistken for pthologicl periostel rection on medil spects of oth the femor (rrows). This norml vrint cn e present up to 6 months of ge nd reflects rpid one growth rther thn disese stte Another exmple, more ovious, in norml 5-month-old The rdius must e in direct reltionship to the cpitellum, regrdless of the position of the elow. The ft-pd sign is n especilly vlule clue in trum (Fig. 7.21). Stress frctures, lthough unusul, my occur in the proximl tii, usully following extreme exercise (Fig. 7.22). A toddler s frcture, seen in children etween the ges of 9 months nd 3 yers, is n olique, nondisplced frcture of the distl tiil shft (Fig. 7.23). The slipped cpitl femorl epiphysis is Slter I frcture of the femorl hed (Fig. 7.24). This injury is found in dolescents, nd there is significnt (25%) incidence of ilterlity. Metphysel corner frctures, multiple injuries, nd, prticulrly, posterior ri frctures, re clues to child use (discussed elow under Nonccidentl Injury ).

16 184 7 Skeleton c Fig Nursemid or supermrket elow, Lterl nd frontl elow films with line drwn through the shft of the rdius show tht the rdius does not rticulte with the cpitellum (C). This disloction is cused y shrp pulling motion, cused in the old dys y nursemid nd in more modern times y prent or gurdin pulling child. It often occurs in the supermrket, hence the nme c, d Norml lignment. R, rdius; C, cpitellum d

17 Trum 185 Fig Positive ft-pd sign The posterior ft pd (lck) is displced so tht it is now visile (rrow). This reflects joint effusion nd, in the setting of trum, is considered n indirect sign of frcture. There is lso lrge nterior ft-pd sign (rrowhed). This is less specific for frcture Fig Stress frcture Frontl rdiogrph of the tii shows zone of sclerosis (rrows) long the proximl shft. There is lso periostel rection Fig Toddler s frcture An 18-month-old girl with limp. This lterl view of the tii shows sutle olique frcture (rrow). It ws not seen in the frontl film (not shown)

18 186 7 Skeleton Fig Slipped cpitl femorl epiphysis This film of the hips in this teenger ws tken in neutrl position nd shows symmetry of the physis. The left physis ppers wider (rrow), nd the femorl hed ppers medilly displced. In ll suspected cses of slipped cpitl femorl epiphyses, frog-leg lterl film is tken Frog-leg lterl film shows complete seprtion of the left femorl hed (rrowhed) nd neck of the femur. This requires surgery hip pinning Cross-Sectionl Imging of Trum Suspicion of frcture on the plin film cn e further investigted with CT. Some frcture disloctions re est evluted with CT. It is lso vlule in res difficult to see with routine rdiogrphs. These include the scrum, pelvis, hips, nd nkle (Fig. 7.25). Where does MR fit in the work-up of skeletl trum? MR is super when one is interested in detecting injury to the growth plte or the formtion of crtilginous r crossing the growth plte ( r my susequently develop secondry to trum nd prevent further growth in tht region; the entire one cn e deformed). MR is lso indicted for osteochondritis dissecns, internl derngement of joints, nd ligment nd tendinous injury. This is especilly true of knee injuries, where MR hs revolutionized the work-up of trum (Fig. 7.26). It is not unusul to find lesion in the proximl tii or distl femur which ws not seen on plin film. This represents ruise (or contusion) of one nd often cn explin the ptient s symptoms. It is of low signl on T1-weighted nd high signl on T2-weighted sequences. Even ultrsound hs plce in the work-up of trum. Rdiopque foreign odies such s metl or glss re esily demonstrted y plin films. Sonogrphy is excellent in finding nd guiding the removl of nonopque soft tissue foreign odies. CT my lso e good in this regrd, lthough sonogrphy is esier, quicker, involves no rdition, nd is less costly. Fig Frctures on CT CT of the pelvis in motor vehicle ccident victim shows sutle frctures of oth ilic ones (rrows). Notice enlrgement of the left ilicus (I) muscle from hemtom. The ldder (B) is hlf filled with contrst

19 Nonccidentl Injury (Child Ause, Bttered Child) 187 Tle 7.7. Specificity of rdiologic findings in non-ccidentl injury. (From [8] with permission) High specificity Clssic metphysel lesions Ri frctures, especilly posterior Scpulr frctures Spinous process frctures Sternl frctures Moderte specificity Multiple frctures, especilly ilterl Frctures of different ges Epiphysel seprtions Verterl ody frctures nd suluxtions Digitl frctures Complex skull frctures Common ut low specificity Superiostel new one formtion Clviculr frctures Long one shft frctures Liner skull frctures Tle 7.8. Nonosseous mnifesttions of child use Fig Sgittl proton density imge of the knee shows liner ter in the posterior horn of the medil meniscus extending to the inferior rticulr surfce (rrow) Nonccidentl Injury (Child Ause, Bttered Child) The rdiologist my e the first person to suggest the dignosis of nonccidentl injury (child use, ttered child syndrome, shken y syndrome). Since the infnt is not very moile during the first yer of life, inflicted injury should lwys e considered in ny infnt who hs frcture without plusile mechnism of injury. Although ny frcture which is inconsistent with the given clinicl history should e suspect, some prticulr types of frctures re considered highly specific for child use (Tle 7.7). These include multiple frctures in different stges of heling (indicting multiple episodes of inflicted injury), metphysel corner ( ucket-hndle ) frctures, nd posterior ri frctures (Fig. 7.27). In used infnts, one my lso see periostel new one in the sence of frcture; this should not e confused with the norml ppositionl new one formtion in infnts etween 2 nd 6 months of ge. Intrcrnil Sudurl hemtom (cute or chronic) Brin contusion Generlized hypoxic ischemic injury Axonl shering injury Thorcic Pulmonry/crdic contusion Pneumothorx/hemothorx Adominl Solid viscerl lcertion/contusion Trumtic pncretitis Bowel injury Duodenl hemtom Bowel perfortion In cses of suspected child use, the serch for skeletl injury is performed with full skeletl survey consisting of plin rdiogrphs of the skull, spine, pelvis, thorx, nd extremities. In cses of uncertinty or for follow-up, nucler medicine one scn cn e helpful. Mny nonosseous normlities my lso e seen on rdiologicl studies of children with nonccidentl injury (Tle 7.8). Some of these re discussed elsewhere in this text.

20 188 7 Skeleton c Fig Legend see p. 189 d

21 Osteomyelitis 189 e f Fig Child use Frontl view of n infnt s skull shows disttic right prietl frcture (rrow), c Frontl rdiogrph of the sme ptient s chest () nd olique view of the right ris (c) demonstrte cllus round multiple heling right ri frctures. Notice how the olique view shows the heling frctures of ris 5 7 prticulrly well d The sme ptient s right upper extremity rdiogrph shows periostel rection t the distl humerl metphysis secondry to corner frcture e Chest rdiogrph in nother used infnt revels multiple heling frctures (cllus) in oth clvicles (downwrd rrows), left lterl ris (horizontl rrow), nd posterior ris including the right eighth ri (8) f Chest rdiogrph of different used infnt shows multiple ilterl posterior ri frctures with cllus (rrows) Developmentl Dysplsi of the Hip Developmentl dysplsi of the hip occurs in out 1 in every 1000 neontes. Girls re more prone to this disorder thn oys, with the left hip involved more frequently thn the right. For yers rdiogrphic screening hs een the est tht we could do; instility is not dignosed, ut the persistently dislocted hip is redily seen. The hip is displced lterlly nd posteriorly. On plin films lterl displcement of the femorl neck implies tht the femorl hed (not visile in young infnts) is not covered y the cetulum (Fig. 7.28). Currently, hip sonogrphy is used to dignose the unstle hip (Fig. 7.29). The hip my e scnned in neutrl, flexed, dducted, nd ducted positions with nd without stress, nd pre- nd posttretment evlutions cn e mde. CT nd MRI my e used for evluting the hip in plster. Osteomyelitis Osteomyelitis is usully cquired vi hemtogenous spred of orgnisms to the one. Since the gretest lood supply is in the metphysis, this region hs predilection for osteomyelitis. A smll focus of these purulent orgnisms cuses scess formtion in the mrrow with n increse in locl pressure, followed y locl deossifiction nd destruction of the cortex (Fig. 7.30). The epiphysis is usully spred ecuse of the tight dherence of the periosteum to the metphysis. However, the shft of the one is redily permele to infection s the periosteum is loosely dherent, nd orgnisms my scend the shft of the one or the medullry cvity. Deep puncture wounds my lso cuse osteomyelitis in children. One of the more common orgnisms introduced vi puncture wound is Pseudo-

22 190 7 Skeleton Fig Dislocted hip on rdiogrph AP view of n infnt s pelvis shows lterl displcement of the right femorl neck nd femorl hed. The involved femorl hed ossifiction center is slightly smller thn on the norml left side A 31-yer-old with congenitl ilterl hip disloction. There is pseudocetulum formtion nd cox mgn study is frequently more helpful in the erly dignosis of cute osteomyelitis. The proper study is threephse one scn with 99m Tc-leled diphosphonte. The initil phse is the lood pool nd the second phse is soft tissue segment. These re otined immeditely fter injection. Positive results men incresed lood flow nd soft tissue infection (cellulitis). The delyed scn is the third phse, nd is positive in osteomyelitis nd septic rthritis (Fig. 7.31). If the dignosis is mde promptly nd tretment is successful, heling usully occurs without significnt growth disturnce. However, prolonged infection prior to the dignosis or severe involvement of joint septic rthritis cn hve long-term sequele. The rdiogrphic findings of cute, heling, nd chronic osteomyelitis re summrized elow: Fig Longitudinl sonogrphic view of dislocted infnt hip. The femorl hed (F) is not seted in the cetulum, s it should e (compre with Fig. 7.11) mons, while stphylococcl osteomyelitis is most common in hemtogenously spred disese (see Fig. 7.14). Ptients with sickle cell disese re susceptile to Slmonell osteomyelitis. The clinicl symptoms precede the rdiogrphic findings y 7 14 dys. For this reson rdioisotope Acute osteomyelitis (0 2 weeks) Soft tissue swelling initilly Loss of corticl mrgin Focl deminerliztion of one Fint periostel new one formtion (7 14 dys fter onset) Heling phse (>4 weeks) Destroyed one with irregulr res of sclerosis nd lysis Sequestrum: dense devsculrized one frgment within n re of pus mid grnultion tissue

23 Osteomyelitis 191 Fig Osteomyelitis Lterl view of the distl femur shows periostel rection nd sclerosis (white re) in the dimetphysis CT of the sme femur tken 1 month lter. The osteomyelitis continued nd now we see sequestrum (S) in the center of the femur nd low density pus (P) surrounding the cortex c MR shows the mrrow involvement nd soft tissue normlities in exquisite detil c Involucrum: peripherl shell of supporting one lid down y the periosteum round the old disese Chronic osteomyelitis (either unusul loclized osteomyelitis or improperly treted) Diffuse one production with little or no destruction Occsionl drining sinus or lucent re in the midst of the sclerotic one MR hs definite role in the work-up of osteomyelitis, especilly in the chronic nd indolent form (Fig. 7.32). MR is especilly useful in septic rthritis s it cn demonstrte crtilge loss, joint effusion, synovil hypertrophy, nd one destruction. When the rdiogrphic or scintigrphic findings re equivocl or hrd to evlute, MR is lso useful. This is especilly true when deling with certin flt ones tht re hrd to visulize on plin rdiogrphs such s the sternum, scpul, nd pelvis (Fig. 7.33). Certin children re t high risk for osteomyelitis nd its complictions. These include neontes who hve high incidence of oth -streptococcl osteomyelitis nd septic rthritis. In neontes osteomyelitis is frequently multifocl. Ptients with sickle cell disese hve high incidence of Slmonell osteomyelitis, which is lso frequently multifocl, ut the most common orgnism in one infection of ptients with sickle cell disese is Stphylococcus. Children with immune deficiencies such s chronic grnulomtous disese nd gmmgloulinemi re prone to multifocl osteomyelitis or osteomyelitis in unusul res such s the ilic ones; this is frequently due to unusul orgnisms (Fig. 7.33).

24 192 7 Skeleton Fig Osteomyelitis Left femur with distl periostel rection Anterior view of the femor on 2-h delyed imges of 99m Tc-leled diphosphonte scn revels incresed uptke in the distl left femur, Fig Chronic osteomyelitis, Plin rdiogrphs show dense corticl thickening nd res of lucency in the medullry cvity of the distl humerus c Axil T2 ft-sturted MR demonstrtes sinus trct (white) through the posterior cortex of the one nd djcent soft tissue inflmmtion c

25 Metolic Disorders 193 Fig MR of osteomyelitis Coronl T1 scn shows diminished signl in the left ilic one mrrow (rrow) This is confirmed in xil T1 imges (rrow) Bone Infrct Bone infrcts re seen in numer of disorders, including sickle cell nemi, pncretitis, Gucher s disese, nd steroid therpy. When it is idiopthic nd ffects the femorl hed, it is clled Legg-Clvé- Perthes disese (Fig. 7.34). Plin films re not le to differentite infection from infrction in sickle cell disese, ut in other disorders dense one tht eventully frgments is typicl for infrction. MR is especilly well suited for the dignosis of infrction since it is mrrow disorder. Metolic Disorders The growing skeleton is susceptile to mny nutritionl deficiencies nd reflects the dequcy of the homeosttic mechnisms (gstrointestinl trct, liver, kidneys) for hndling clcium. Two of the more common disturnces in this ctegory re rickets nd hyperprthyroidism. Both diseses re usully secondry to chronic renl disese. Rickets. In rickets there is deficiency of vitmin D nd, therefore, poorly minerlized osteoid tissue. The trecule re fuzzy nd irregulr nd certinly not s distinct s those in norml one. The metphysel Fig Legg-Clvé-Perthes disese Frontl view of the hips revels frgmenttion of the right cpitl femorl epiphysis regions re irregulr, with cupping nd frying of the ones (see Fig. 7.15). The pprent distnce etween the metphysis nd the ossifiction center is greter thn norml, s there is n undnce of unclcified crtilge. Despite ll our dvnces, the most common cuse of rickets in the world tody is still nutritionl vitmin D deficiency. However, in most medicl centers the most common cuse of rickets is chronic renl disese since the kidney cnnot hydroxylte vit-

26 194 7 Skeleton Fig Hyperprthyroidism Hnd showing sclerosis t wrist nd superiostel resorption of the rdil spects of the middle phlnges (rrows) The corticl mrgins of the neck (oth medil nd lterl) of the femur re not visile due to one resorption (compre to neck of femur in Fig. 7.1). Also note the lytic lesion in the greter trochnter. This rown tumor is the result of ccumultion of firous tissue nd gint cells nd hs ll the chrcteristics of enign one lesion. A sclerotic order nd the cler zone of demrction re evidence of its enignity min D. Children with liver disese lso my mnifest rchitic chnges ecuse of the liver s role in vitmin D hydroxyltion. In premture infnts, the entire process of sorption nd conversion of clcium into one is impired. Rickets of premturity in this popultion is demonstrted y right corticl one nd wshed-out medullry cvity. The ones re not cupped or fryed ecuse the infnts re not growing. Hyperprthyroidism. In this disorder one resorption fr exceeds one prolifertion (osteoclsis fr exceeds osteolstic ctivity), nd s result the one is resored. Rdiogrphiclly one sees superiostel one resorption most often long the diphyses of the phlnges (Fig. 7.35), t the distl clvicles, nd long the lmin dur of the teeth. Diffuse deminerliztion nd focl lucent lesions (rown tumors) re other signs of this disorder (Fig. 7.35). In chronic renl disese, clcium loss through the urinry system is usully so gret tht the prthyroids must drw clcium into the circultion from the existing stores in ones to mintin norml clcium phosphorus rtio. Led Intoxiction. Hevy metls such s led or ismuth stimulte incresed clcifiction of crtilge, which cuses incresed density in the metphysel regions. The density is found in oth lrge, weightering ones s well s smller ones (e.g., tii nd fiul) nd in other res where longitudinl one growth is occurring most rpidly (Fig. 7.36). Rememer: the uln nd fiul re the key ones for determining led intoxiction. The femur, humerus, nd rdius often hve dense metphysel nds normlly, ut never the uln nd fiul. The finding of led lines correltes with chronicity of exposure nd not with lood led levels or cute symptoms.

27 Bone Tumors 195 ri (Fig. 7.37). Osteoid osteom is sclerotic lesion with centrl lucent nidus. It occurs in mny plces, including the long ones nd spine. Mlignnt Lesions Fig Chronic led intoxiction The metphyses of ll the ones, especilly the fiul, re sclerotic. This is typicl of hevy metl ingestion.while the femur, tii, nd humerus often hve equivocl density in the metphyses, the uln nd fiul should not e dense t ll. Consequently, ny metphysel density noted in the ltter two ones should rise the suspicion of hevy-metl intoxiction. Bone Tumors Mlignnt one tumors re not common in children, ut enign one lesions re frequently seen. Some of the common enign nd mlignnt lesions re descried elow. Benign Lesions Simple one cyst is lucent defect t the metphysis of long one ner ut not touching the physel line. It is most often found in the humerus, femur, or tii (Fig. 7.37). Firous corticl defect is well-circumscried, ellipticl lucent lesion in the cortex t the end of long one, prticulrly the femur or tii; the lrger ones re clled nonossifying firoms. Osteochondrom (exostosis) is protuernt growth of one from the metphysis tht hs contiguous corticl mrgins (Fig. 7.37). Enchondrom is crtilginous, cyst-like lesion often seen in the phlnges nd Osteogenic srcom occurs mostly during dolescence, frequently in the long ones; this is the most common primry mlignnt tumor in the peditric ge group, nd it is metphysel nd one-producing. Ewing s srcom is the second most common tumor in peditric ge group; it is more common thn osteogenic srcom in those under 10 yers of ge (Fig. 7.38). This lesion my occur in ny one in the mid-diphysel region nd is permetive. There is lrge soft tissue component. It is frequently found in flt ones, such s those of the pelvis. Systemic mlignncies of one such s leukemi, neurolstom (metsttic), retinolstom (metsttic), nd heptolstom (metsttic), re importnt in the differentil of permetive lesions. The ppernces of these four diseses plus Ewing s srcom nd osteomyelitis re ll similr nd frequently cnnot e specificlly dignosed y X-ry. The rdiologist must decide whether the lesion is enign or mlignnt. Cler signs of enign lesion include shrp demrction etween the lesion nd the norml one, sclerotic mrgin round the lesion, nd nonggressive pttern of growth. The chrcteristics most often ssocited with mlignncy include n ccompnying soft tissue mss, periostel rection, n indistinct zone etween the norml nd norml one n indistinct zone of demrction nd permetive, destructive chnges in the one (see Fig. 7.38). Plin film rdiogrphy is usully dequte to dignose most enign tumors. Sometimes CT cn dd dignostic informtion tht cn e helpful, such s in osteoid osteom, where loction of the nidus is criticl for opertive mngement. While plin film is still quite relile for predicting the enign or mlignnt nture of lesions, MR is the modlity of choice to define the extent of the normlity once mlignnt one lesion hs een suggested. The extent of the lesion mens defining corticl nd intrmedullry invsion, epiphysel, joint spce, ligmentous, tendinous, nd nerve undle involvement. MR evlution ids in the decision to perform lim slvge procedure or n mputtion nd is helpful in following response to chemotherpy. Rememer, however, tht histologicl dignoses cn only e suggested; only iopsy cn result in firm dignosis.

28 196 7 Skeleton c Fig Benign one lesions Simple one cyst. The proximl humerl lesion is well demrcted nd is lucent. There is pthologic frcture through the lesion. A fllen frgment of one is seen within the cyst cvity, c Osteochondrom. The plin film () shows rod-sed lesion from the proximl humerl metphysis. The medullry cvity of the lesion is contiguous with tht of the one. The xil T2-weighted MRI (c) shows the cp of crtilge (rrow) growing over the osteochondrom d, e see p. 197

29 Bone Tumors 197 d Fig (continued). d, e Enchondroms. This ptient hs multiple enchondroms on one side of her ody, condition known s Ollier s disese. These lesions contin multiple smll, ring-like densities, sign of crtilge. Notice the ssocited growth disturnce, foreshortening of the uln, nd owing of the rdius e

30 198 7 Skeleton d c Fig Legend see p. 199

31 Mrrow Disorders 199 Fig Norml pttern of mrrow conversion. (From [9] with permission) Soft Tissue Tumors The first exmintion in evluting ny soft tissue mss is still the plin film. When the ptient hs plple lesion, plin films cn rule out underlying skeletl deformity, such s exostosis or cllus formtion overlying frcture. Clcium, in the form of phleolith in venous mlformtions or s periostel rection in myositis ossificns (clcifying hemtom nd muscle dmge fter trum), is n importnt clue. The plin film my lso e helpful in detecting periostel rection, destruction, nd remodeling of underlying one. MR is super for the dignosis of soft tissue tumors ecuse it cn rule out msses in virtully 100% of cses. Benign soft tissue msses tend to e shrply defined, encpsulted, nd homogeneous with no peritumorl edem, while mlignnt msses tend to hve indistinct mrgins, tend to e inhomogeneous, nd hve peritumorl edem in over 90% of cses. Specific dignoses cn e mde for certin types of tumors if they contin ft or re vsculr lipom, liposrcom, hemngiom, rteriovenous mlformtion, pseudoneurysm, gnglionic cyst, nd hemtoms. MR is lso super in detecting fluid levels inside certin lesions. Mrrow Disorders It is importnt to e fmilir with the norml pttern of conversion from hemtopoietic to ftty mrrow in the skeleton (Fig. 7.39). MR hs ecome the modlity of choice in evluting diseses of the one mrrow. Becuse MR cn seprte ft from other tissues, it is excellent in ppreciting the norml ptterns of one mrrow distriution nd the response of the mrrow to the stress of disese. The disorders in which MR imging is super re: Myeloid hyperplsi (nemi, cynotic hert disese) Mrrow replcement disorders (leukemi, Gucher s disese, neoplsms, lymphom, metstses) Myeloid depletion (drugs, virl infections, rdition therpy toxins) Myelofirosis (chemotherpy, rdition, infrction) MR imges the mrrow y visulizing the ft content; ft-suppressing techniques id in dignosing infiltrtive diseses. Mrrow contins ft, nd s the infnt grows into dulthood, the mount of ft in the skele- Fig Mlignnt lesions Ewing s srcom. This rdiogrph of the distl fiul displys mny of the findings of mlignnt one lesion. The fiul hs disordered periostel rection oth medilly nd lterlly nd the extensive one destruction without cler zone of demrction etween norml nd norml suggests mlignncy. The distl tii is norml d Osteogenic srcom. AP nd lterl views of the distl femur (, c) show dense, undnt periostel rection with sunurst ppernce nd irregulrity of the ony cortex. Coronl T1-weighted MR imge (d) of the sme ptient demonstrtes the extent of mrrow involvement (compre to norml left side) s well s the soft tissue component of the tumor. The tumor extends distlly to the growth plte ut does not involve the epiphysis

32 200 7 Skeleton Fig Mrrow evlution with MR T1-weighted imge of the pelvis in 10-yer-old with sickle cell nemi demonstrtes diffuse myeloid hyperplsi. The mrrow should e right, ut insted it is diffusely drk, including the epiphysis Fig Bone mrrow infrction on MR Ft-suppressed inversion recovery imge of the pelvis in the sme ptient s Fig shows multiple right res of infrction, especilly in the right cpitl femorl epiphysis nd femorl diphysis ton increses nd the mount of cellulr (hemtopoietic) mrrow decreses. The mrrow chnges in the ppendiculr skeleton first nd grdully moves centrlly towrds the xillry skeleton. Since the ftty mrrow is right nd the cellulr mrrow is drker, normlities re esily recognized (Fig. 7.40). For exmple, the epiphysis lmost lwys contins ftty mrrow. Thus, n infrct in the epiphysis is redily detected (it is lck on T1-weighted imges nd right on ft-suppressed T2-weighted imges; Fig. 7.41). Arthritides The most common cuse of joint swelling in children is trum. Usully the history is otined, nd the injury is short-lived. The second most common cuse of rthritis is infectious the septic joint. The common orgnisms in childhood re Stphylococcus nd Streptococcus, ut the uiquitous gonococcus cnnot e forgotten. Although rdiogrphs my show evidence of joint effusion nd swelling, ultrsound nd MR re fr more sensitive for effusion, synovil chnges, nd crtilginous normlities. Approprite clinicl mneuvers such s tpping the joint re dignostic. Less commonly, rheumtoid rthritis, hemophilic rthritis, nd rthritides of collgen disese re found (Fig. 7.42).

33 Arthritides 201 c Fig Arthritides Hemophili. Shoulder with ony erosions (rrow) nd glenohumerl joint spce nrrowing. There is mixed sclerosis nd lucency in the proximl humerus Hemophili. There is overgrowth of the ones ner the right elow joint c, d Lte juvenile rheumtoid rthritis. AP nd lterl views of this 8-yer-old s elow show perirticulr osteopeni nd loss of joint spce. The rticulr surfces re irregulr d

34 202 7 Skeleton Congenitl Anormlities Congenitl nomlies involve normlities of position (verticl tlus; Fig. 7.43), numer (polydctyly), size (chondroplsi; Fig. 7.44), nd shpe (proximl femorl focl deficiency PFFD; Fig. 7.45) of ones. These my e ccompnied y soft tissue nomlies, such s vsculr mlformtion. QUIZ CASE Wht normlities do you see in Fig. 7.46? Fig Congenitl verticl tlus The xis of the tlus (T) should e more horizontlly oriented nd form 120 ngle with the clcneus Fig Achondroplsi The proximl long ones of the extremities re short nd the femor hve n ice crem scoop ppernce. The pelvis hs chrcteristic chmpgne glss configurtion The interpediculte distnces (lines) of the lumr spine decrese rther thn incresing s they should

35 Quiz Cse 203 Fig Proximl femorl focl deficiency The right femur is shorter thn the left nd the proximl right femur is not ossified, c Fig Wht re the normlities in these cses? (Answers in Appendix 2) A 10-yer-old with elow pin A 2-yer-old with knee pin c A teenger with heel pin d n see pp. 204, 205

36 204 7 Skeleton d, e f g, h Fig (continued) d A teenger with leg pin e An 8-yer-old with right nkle pin f A 6-yer-old with swollen right nkle g, h A neworn with swollen extremities i A 10-yer-old with ump on leg i

37 Quiz Cse 205 j k l, m Fig (continued) j An 8-month-old with symmetric glutel folds k A 7-yer-old with left hip pin l A 5-yer-old with right hip pin m, n A teenger with right knee pin n

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