Case 1

Radiograph of the legs of child with abnormal gait. You may observe that there is exaggerated medial bowing of both tibial shafts. There are many causes for bowing, including genetic predisposition, constitutional variation as well as deformity secondary to soft bones –etiology includes rickets, osteogenesis imperfecta  etc. In this patient you also notice that there is presence of a vertical talus with resultant flatfoot. Student may delve further into these areas for precise measurements, angles and how to document the report.

Case 2

8-month-old child with the protuberant abdomen, hypotonia and lethargy. 

Radiographs of the wrist demonstrate classic appearance of active rickets. Metaphyseal flaring, irregularity and subtle sclerosis in the zone of provisional calcification is noted. There is gross widening of zone of provisonal calcification due to abundant clusters of partially calcified/non-calcified cellular matrix. Similar subtle changes are noted in the distal ulna. Rest of the bones are osteopenic. 

Case 3:

3-month-old neonate with the hypotonia and lethargy. Child cries incessantly. 

Example is a classic set of radiographs for the student of radiology. Skull appears unremarkable. Note that sutures are wide in the neonatal period. Did you notice any other abnormality? What about the CT images? There are subtle hypodensities in the high frontal convexity on the right side and the bilateral symmetrical white matter hypo density in the parieto occipital region. Clue to the diagnosis is in the long bones. Your attention should be drawn to subtle metaphyseal fractures of the distal femur and both ends of tibia. This is a bucket-handle fracture typical for child abuse. If you notice further, there are subtle injury to both distal radii. Brain changes are due to resolving contusions. This is a medical legal issue hence notification to appropriate authority is necessary.

Case 4:

Chest frontal and lateral views are performed for the history of stridor. Did you notice any abnormality in the airway or the chest? Well, the chest radiograph is essentially normal. The abnormality is in the fracture of right clavicle, a finding very obvious. Clavicle fractures may be undiagnosed at birth, are fairly well known in difficult labour. Due attention should be paid when radiograph is done for other indications.

Case 5:

A set of radiograph in a child with an abnormal head and failure to thrive. Any clue to the diagnosis? What are your observations?

There is scaphocephalic macrocephaly. Also, the bones appear to be thickened especially in the mid convexity diploic regions. Now you should be able to get some supportive observation in the other radiographs. Is there evidence of marrow widening? Yes, it is very obvious in the metacarpal bones which are also grossly osteopenic. Thickening of the bone is noted in the posterior elements of the vertebral bodies, especially in this case the spinous processes. Overall findings are indicative of a marrow disorder. In this case the diagnosis was thalassaemia major.

Case 6:

Two radiographs of the leg and thigh in a 3-month-old girl. The radiographs are of the right and left lower limbs. You should be able to identify the radiograph and provide a diagnosis. This is the same case presented earlier, a case of child abuse with bucket-handle fracture on the right side involving femur and tibia. On the left side there is a tell tale evidence of an earlier injury with the abundant callus formation. The limb also is extremely swollen probably due to muscle hematomas and inflammatory reaction. Multile fractures at different stages of healing should alert the radiologist to look for subtle signs of child abuse.

Case 7:

A child with multiple anomalies and deformed hands. This is a syndromic child with multiple abnormalites. One element of the syndrome is present in the distal ulna in the form of an exostsis with madelung deformity. Also note abnormal appearance of the metacarpal and phalangeal bones, with relatively widened, osteopenic metaphysis. Further elucidation of the syndrome needs complete skeletal survey, clinical observations and genetic testing. (Complete evaluation not performed in this patient)

Case 8:

Skull frontal and lateral views of the newborn is provided. 

The radiographs are somewhat darker appearing!! Required observations are however clearly present. Notable observations are a large anterior fontanelle, multiple Wormian bones in the lambdoid region and the osteopenic appearance of elongated skull. This is part of the skeletal survey of the patient with osteogenesis imperfecta, shown to you in different ways.

Case 9:

This is another 4-year-old with anaemia, on treatment for a known disease. These observations are not common in the present day, as evaluation modalities have undergone change. If you are a careful observer, you will notice in the chest radiograph metaphyseal radiolucency and bandlike radiodensity in proximal humeri. These findings are illustrated in the localized views. Metaphyseal radiolucency can be due to various causes including rickets, acute systemic infections, infiltrative disorders etc. In this case patient was known to be leukaemic.

Case 10.

Neonate with the abdominal distention, limb deformity and abnormal eye. These two radiographs are a classic example for plain film analysis. What is your observation and impression? 

Please note that bones are slender and osteopenic. On further evaluation you may also notice multiple rib fractures and hardly visualized similar changes in the long bones. Additionally there appears to be a soft tissue swelling in the region of scrotum, which was due to a larger inguino-scrotal hernia. These findings are very common in osteogenesis imperfecta.

Case 11:

This is an adult with a history of trauma. Trauma radiology is a very important part of student radiologist training. Not all are exposed to this important area. Certain obvious observations are generally made but not a complete set of observation. In this case a longitudinal metaphyseal fracture of the distal tibia and undisplaced fracture of calcaneum is obvious. The question is whether the ankle mortise is intact? Is the mortise stable? To answer this question you have to scrutinize the distal fibula and assess whether medial malleolar fragment is stable. In this case there is also subtle fracture of distal fibula, and observation of great importance in the management.

Case 12:

A neonate with multiple limb deformity. The deformity of the limb is too obvious and is due to bent bones. The reasons for bending of the bone is not due congenital bone shortening but the result of multiple fractures and remodelling of the bones. Upper and lower limbs are affected. Also there is wedging of vertebrae in the dorsal region. This is a classic appearance of osteogenesis imperfecta in the neonatal / infantile form. We have gone through part of the skeletal survey elsewhere in the series.

Case 13: 

This is a 10-year-old male with leg pain. Do you have a diagnosis in mind? Are there any bony injuries? Areas of increased soft tissue densities are noticed lateral to the tibia in the upper and mid leg region, which also extend laterally beyond the outline of fibula. No obvious injury is noted in the visualized bones. This appearance could be either due to interosseous membrane calcification or myositis ossificans. It appears that it is extension beyond the anatomy of interosseous membrane favors the diagnosis of myositis ossificans.

Case 14: 

14-year-old male with the intermittent fever and joint pains. Do you have any observation on the chest radiograph? Does it look normal? 

The left clavicle obviously appears larger and sclerotic. This patient underwent MR examination of the clavicle as well as the spine. Any possible diagnosis with this combination? This patient shows a laminated periosteal new bone formation in the clavicle in the form of onion ring-shape seen in the MR view of clavicle. Also there is inflammation around the clavicle, showing intense enhancement. Changes are also noted in the spine in the form of reduction in the disc space and the vertebral heights at multiple levels. No obvious collections are noted. Patient was negative for tuberculin test. In this case the diagnosis of chronic recurrent multifocal osteomyelitis (CRMO) was made.

Case 15

This illustration provides limited skeletal survey examinations of a 3-month-old female with a relatively large head and short limbs.

Examination of the chest is grossly unremarkable although scapulae look abnormal.  What is your diagnosis based on the skeletal survey? In fact, this is one of the common syndrome that is encountered in paediatric practice. The child often presents with short stature, involving proximal, middle and distal elements. Sacrum is somewhat horizontal, leading to a prominent gluteal bulging. Relatively large head is noted. Rest of the growth parameters and developmental milestones are expected to be normal. On radiography there is acromelic, mesomelic and rhizomelic shortening. Metaphyseal ends are flared and relatively larger. Bone density is generally normal. Iliac bones appear flared show horizontal acetabular configuration. Most important observation is the narrowing of the spinal canal, most manifest in the lumbar region. Relatively large calvaria with a small foramen magnum are generally present. Long-term complications could be a possibility due to narrow foramina magnum.

Case 16:

7-year-old child with a history of painful elbow following a fall.

Since this is a straight forward AP, Lateral skeletal radiograph, you should be able to make some important observations need for diagnosis. Did you see a fracture? Is there any other abnormality? 

Assessment of the elbow is an important requirement in pediatric imaging. Identification of subtle bony injury, often needs thorough scrutiny and often magnification of the area of interest for analysis. Also review of the fat planes around the elbow is important to gather clues to the possible joint fluid. In this case the anterior as well as the posterior fat pads are displaced. Other relevant requirement is familiarity of appearance and sequence of ossification centers around the elbow..On careful scrutiny you will notice that there is a cortical break in the anterior cortex of the distal metaphysis of humerus. Subsequent image with arrows may be of help the student in understanding the observations better.

Case 17

This is a 2-year-old febrile child with a painful arm.

MR images are provided in coronal and axial planes. Obvious finding is minimal fluid in the shoulder joint. There is soft tissue oedema around the shoulder. Coronal contrast-enhanced T1W image shows synovial enhancement and tiny collections in the proximal, medial metaphysis of humerus. This was a case of septic arthritis.

Case 18

2-month-old infant, continuously crying and irritable. Limited movements of the lower limbs.

This is an AP/oblique view of lower limb radiographs. The predominant finding is osteopenia with a sharp sclerotic appearing cortex and somewhat radiolucent medullary cavity. If you carefully notice there are multiple subtle fractures of metaphysis at multiple levels almost involving all long bones. There is a large area of calcification around the proximal metaphysis of the left femur, representing a calcified subperiosteal haematoma/exuberant callus. In this age group these findings could be due to conditions like osteogenesis imperfecta. In an older child scurvy can produce very similar observations. Osteopenic bones are not a classical observation in cases of child abuse, which is also a diagnosis in a slightly older child

Case 19:  Adolescent female with a waddling gait.

Frontal and lateral lumbosacral spine radiographs demonstrate a classical grade 4 spondylolisthesis. In the frontal view the distal sacrum is not well seen. Prominent ‘bow’ of the sacral promontory is also noted. This patient also demonstrates somewhat hypoplastic posterior elements at L5, probably due to a developmental defect. CT/MR examinations are essential for planning corrective surgical procedures.

Case 20

For the first look everythings looks fine.On careful scruitiny, on the lateral view, you will see a ftagment of bone forn tibial epiphysis. This fracture is unlikely to be seen in the frontal view. Certaily there is a role for a CT?MRI imaging to confirm bony injury and exclue ligamentous damage.

Case 21

Painful elbow, frontal and lateral views.

Another good practice radiograph, for exam going students. Do you have any important observations or do you think is it normal radiograph? Fracture is present, nicely camouflaged. At subtle signs of the elbow joint fluid is present in the form of positive fat pad sign. On close scrutiny, an inverted V shaped fracture in the distal humeral metaphysis is present.

Case 22: 8-month-old child with the gait abnormality.

This 8-month-old child presented with the limb deformity in the form of bowed legs and a large head.

Evaluation of the bones or gait abnormality should evaluate bones from pelvic level to the calcaneus, especially if there is a discrepancy in length. Often CT scanogram is used for this purpose in view of relatively lower radiation dose. However structural diagnosis is limited in CT scanogram. This patient has a bowing of the long bones with the medial concavity. Bones are extremely thick in the central part and show reinforcement of cortex in the medial aspect. There is metaphyseal widening, osteopenia and flaring. If you are an astute observer, femoral metaphysis, show likely erosions in the medial aspect. Indeed this patient had active rickets, put on treatment and had this deformity due to severe disease. Metaphyseal erosions are not part of a classical rickets. Erosion appears somewhat organized with a corticated margin indicating a benign process.

Chest radiograph of the same patient is provided. In this case, based on the radiograph alone, you cannot make a diagnosis. But note that there is a metaphyseal flaring of the proximal humeri. Also there is a bell-shaped chest deformity which is somewhat broad in the lower chest. . Anterior ends of the ribs are also somewhat flared. Gross widening of anterior rib end contribute to the clinical appearance of 'Rickety Rosary'

Case 23

Adolescent with the leg pain following minor trauma.

Frontal and lateral views of the proximal leg and the knee are provided. What do you think is the cause of the pain? Is it a straight forward injury with healing by callus? Can this be a result of a minor trauma?  Well, radiologists with good exposure will immediately point out the diagnosis as a pathological fracture in a non-ossifying fibroma. There is a well corticated, lobulated, peripherally located lesion in the proximal tibial metaphysis. When lesions are large can lead to a pathological fracture following a minor injury

34-year-old male with bilateral hip pain, limitation of movement.

Plain x-ray and the MR images are provided. This is not a difficult diagnosis to make. You may notice subtle abnormalities on the plain radiography. Minimal irregularity, sclerosis of the both femoral heads is observed. More evident observations are possible on MR images. T1 -weighted images demonstrate some cortical irregularity and sclerosis (T1 hypointense), which on STIR  images show slight hyperintensity. There is suggestion of subcortical collapse/condensation. These areas may show contrast enhancement. (Not done in this case ). Subtle joint fluid also can be observed as noted on the right side. This is a case of bilateral avascular necrosis of femoral head.( 40% of the total) Etiology is many fold, common being trauma, alcoholism, steroid therapy and many conditions with small vessel  vasculopathy. Typical location of involvement is antero-superior head, 10-2 o clock position. Quantization of the extent of involvement is very important and several modality based classifications are suggested.(like Ficat, Micheals, Caterells staging)  Prognosis is generally good. Post 'drilling' images give a appearance like advancing disease, though patient may be symptom free. 

Case  25

This is an 18-month-old child, hypotonic not walking and history of a urinary recurrent UTI.

Perhaps clinical input is not helping much in interpreting this chest radiograph. It does have the information. I want you to notice images of the shoulders provided. You will notice that the bones are osteopenic and show metaphyseal irregularities and widening of the epiphyseal plate. Additionally there is cardiac enlargement. Either this patient has a metaphyseal dysplasia or some growth abnormality of the metaphysis.  Additional images of the pelvis are provided. What is your impression of these studies? Obviously bones appear osteopenic. There is a deformity of the femoral necks, which can be likened to the ‘Shepherd’s crook’ deformity. Despite a deformity, metaphysis shows reasonable sclerosis and there is no gross widening. As mentioned this patient had recurrent UTI. Sonographic imaging of the urinary system was done. Both kidneys are small, show gross dilatation of the pelvicalyceal system and ureter. Renal parenchyma is echogenic, grossly reduced in thickness. No, you should get the final picture. This patient has chronic renal failure and bony changes of renal osteodystrophy. By the way what is the likely cause of cardiac enlargement?

Case 27

6-year-old child with pain in the ankle joint of 6 months duration. 

Plain radiography and MRI imaging of the ankle joint are provided.

Single joint involvement in a child is often due to septic arthritis. No signs of sepsis noted in this patient. This child on plain radiographs demonstrates localised soft tissue swelling along the posterior aspect of the ankle. Anterior fat planes are well preserved. Articular margins of the bones appear intact. On MR imaging there is a trace of fluid, not enough to distend the joint cavity significantly. Subtle T2 hyperintensity is noted along the posteromedial aspect of the ankle joint. But the soft tissue element posterior to the ankle joint is a T1 and T2 hypointense. Is it a loose body? Is it a synovial disease like PVNS. Is it due to hemosiderin deposits? More questions can be asked in adults but not in a child.  Diagnosis of the pigmented villo-nodular synovitis is likely in this patient. (Diagnosis not confirmed)

Case 28

This is a 7-year-old child with a history of hereditory disorder.

Radiograph of the pelvis and the right femoral are provided. Are you able to make any observations and conclusions? This radiograph has certain typical features of a disease, if you are familiar you will get the diagnosis. Important observations to note are a severe osteopenia, expansion of the marrow, scalloping of the cortex and modelling deformity of the distal femur. This deformity is called Erlenmayer  flask deformity. These flasks are decorative flasks used in Europe, not very familiar in the Indian subcontinent. These abnormalities can be seen in storage disorders like Gaucher’s disease and Niemann pick's disease. Did you observe mutple subtle cortical fractures in the femoral necks ?

Case 29

A 49-year-old female with low back aches progressively increasing. 

MR Lumbar spine performed, initially at presentation and subsequently repeated after 4 weeks.

What do you think about the initial set of lumbar spine MRI. Is it a vertebral disease or disc disease? The answer is simple: most of the changes are in the anterior superior part L5 vertebra. Posterior margin is not very sharp. Disc appear intact at L4/5 level, somewhat reduced at L5/S1 level.? Degenerative. There is a mild circumferential disc bulge. No obvious soft tissue collections noted. Condition can be area of Osteitis/osteomyelitis, Atypical hemangioma or a neoplastic process.

In the subsequent examination after 4 weeks, the patient has become worse clinically. On imaging also there is gross extension of the disease to the rest of the vertebra, leading to vertebral collapse. Disc space is reduced significantly and there is a diffuse bulge into the spinal canal. There  is suggestion of necrosis/abscess formation.. Progression and pattern of disease spread suggest an inflammatory process, in this instance it was diagnosed as tuberculosis. This patient should have a contrast MR. (outside study, contrast images not available). Acute osteomyelitis can produce similar findings, generally seen in post-operative set up. This patient did not have clinical features of acute osteomyelitis.

Case 30

This is a 5-year-old child with a fall on an outstretched hand. A frontal radiograph is provided.

Be-ware of the interpreting a single radiograph in a trauma context. Two right angle views are must . What are observation in this frontal view? Since this patient has trauma you should identify evidence of injury in the ulnar styloid process. Anything else?  Looks otherwise normal. See the subsequent images. I have provided them in a different page, simply not to give you the pleasure of a direct detection. You will notice that gross observations, noted in the lateral may be missed on single frontal view. Or vice versa. There is complete epiphysioysis of distal radius, with posterior movement of the bony fragment and a chip fracture involving the dorsal aspect of the distal radial metaphysis. Did you notice an area of sclerosis in the distal radial metaphysis in the frontal view? Pisiform is antero-posteriorly oriented. However carpal bones maintain the alignment with the distal bony fragment.  This is a teaching radiograph for all busy, trauma radiologists.

Case 32

7-year-old male with a growth retardation, painful limbs and hepatosplenomegaly.

Radiograph of the pelvis and left femur is provided. Not many young radiologists can report these radiographs comfortably. Important observation is that radiographs do not look very great technically. Why is that?  Obviously the bones are extremely osteopenic, perhaps not very cooperative due to pain.

Apart from osteopenia do you notice anything else? There is medullary expansion, cortical scalloping, abnormal modelling of the bone in the form of gentle expansion of the diaphysis of bone towards the metaphysis ( Erlenmeyer Flask deformity) and subtle areas of cortical break (cortical fractures)  if you are imaginative enough, you would have identified multiple vertebral collapse in the lumbar spine in the top right radiograph.  Having noted all the major observations the diagnosis should be an infiltrative marrow disorder with areas of subtle injury. Generally storage disorders of genetic origin like Gaucher’s and Niemann-Pick’s disease lead to such observations. Haemoglobinopathy are another group of entities which can cause marrow enlargement, osteopenia and organomegaly.  Deformity of the metaphysis as seen in this case, is not a common feature.  In the past skeletal survey was routinely done in such a context. Hands and skull offered useful clues to the diagnosis in haemoglobinopathies like thalassaemia and sickle cell disease.

You are provided with an MR image in this patient. Do you think MR observation is consistent with an infiltrative marrow disease? Did it add anything more to consider the diagnosis of haemoglbinopathy?

MRI examination is not very specific to make accurate histopathological diagnosis. You will have to resort to more specific tests and histopathological evidence. MRI certainly demonstrates the extent of disease. This patient has abnormal signals of the bone marrow. The whole shafts of both femora are T1 hypointense. Additionally, the left femur shows more severe involvement, gross hyperintensity in T1 sequences and some additional soft tissue changes and subperiosteal collection. Indeed this is special information that MRI has provided, in addition to confirming extensive marrow changes. This patient has a subperiosteal collection, which can be either due to subperiosteal haematoma or due to secondary infection with subperiosteal  pus collection. This patient had osteomyelitis in addition to Gaucher’s disease which the patient was diagnosed to have.

Case 33

12-year-old female with hip joint pain. MR imaging in the coronal plane is provided. This is a companion case which has already been illustrated once. Note is that this is an instance of a bilateral avascular necrosis of the femoral head. Changes are subtle. There is a corresponding CT image which shows subcortical radiolucent areas without obvious break in the cortex. What do you think about a band of radiolucency around the femoral head in the images in the second row? They think this is an extensive subchondral disease or if there is any other possibility? Most likely in this case it might represent subchondral disease. Sometimes epiphyseal plates if not completely fused can produce pseudo-subcortical disease signs. All images needs to be reviewed in coronal as well as axial planes.

Case 34

An adult with bilateral foot pain. Frontal radiographs of both feet are available for review.

Do you see any observation of significance? Is there any possibility of a navicular-cuboid fusion? This exercise is conditioning the brain for multiple possibilities. Initially I was led to believe that there is a navicular- cuboid fusion.

Review of other views proved contrary to my impression. Lesson learned in this exercise is that the impression of fusion may be not justified, if it is not shown in all the views. Minor fusion may be seen only on CT images with tailored multiplanar reconstructions. Also there are clinical conditions with elements of both, partial fusion and fibrous union. Borderline cases with clinical symptoms should be investigated throughly.

Case 35

This is a newborn baby with multiple anomalies and bilateral elbow deformity. This limited skeletal survey demonstrates slender long bones with the bilateral superior radio-lulnar dislocation. There are a few syndromes with these characteristic findings. Genetic evaluation is necessary as this deformity can be a part of a complex syndrome. Spectrum of anomaly may vary from complete bony fusion (radio ulnar synostosis) to a fibrous union with hypoplastic bony components. Chromosome abnormalities that may include radioulnar synostosis as part of the syndrome, are Klinefelter syndrome and XXXY syndrome. Other genetic syndromes that have radioulnar synostosis as part of the disease are Apert syndrome, Crouzon syndrome, Carpenter syndrome, arthrogryposis, Treacher Collins syndrome, Williams syndrome, amegakaryocytic thrombocytopenia, and Holt-Oram syndrome.

Have you noticed anything in the chest examination? Image interpretation is a very demanding and unforgiving process. You’re supposed to observe the segmentation anomalies of the lower dorsal vertebra in the form of a hemivertebra. Additionally this patient has cardiomegaly and airspace opacities in the medial right lung. Patient had a left-to-right shunt as well on a clinical and echocariography exam.

Case 36

4-year-old child with Short stature the lower limb weakness was investigated with the skeletal survey and MRI evaluation of the spine.

I have been continuously challenging some of my viewers with cases that they may not  have seen their lifetime. But as a medical curiosity, practitioners may be interested to see the spectrum of disease processes in different body parts.

This disease is not very uncommon in paediatric practice. The skeletal survey clearly demonstrates an abnormal vertebrae in the form of a reduction in the height and anterior inferior beaking. Endplates are irregular. Note is that there is no encroachment of the spinal canal or evidence of spinal canal narrowing. Atlantodental relations appear within normal. Knee joint views are available for review, showing subtle abnormalities in the form of irregularities of the femoral epiphyses. Findings are very subtle. No obvious abnormalities noted in the hip joint or in the ankle. In this instance we may be dealing with a subtle form of the Spondylo epiphyseal dysplasia. The reason for performing MRI in this context is to exclude possible cervical spinal canal narrowing; an observation seen in some patients. You will see that in the spinal evaluation there is no obvious evidence of spinal canal narrowing. We do see disc bulges in the lumbar area at multiple levels. Certainly there is no evidence of bony cervical canal narrowing. 

Though this examination was interpreted as normal at the time of assessment (2 decades ago), now I wonder, why is the cervical cord in close approximation to the posterior elements in all the views? There may be a simple explanation, like incidental positioning. But I believe in view of the patient's symptoms we should have performed a dynamic cervical MR examination. Earlier I have shown you an example of Hirayama disease, a disease of a tight Dural sac with the dynamic cord compression on flexion. Are we dealing with a reverse of Hirayama's disease? The purpose of my web presentation will be fulfilled if one of my younger protege –colleague takes this issue and produces outstanding work in this group of patients with dynamic cervical MR examination. Outcome of such a study might change the outlook of management of patients with spondylo epiphyseal dysplasia.

Case 37

In this child with the joint pains,  images of ankle joint and shoulder joint are provided. Indeed no obvious abnormalities visible in the ankle joint. Subtle soft tissue calcified appearing density in the medial aspect of the leg is an artefact. Any abnormality in the shoulder? The shoulder joint also appears normal. Observations are in the outer end of the clavicle which demonstrate lamellated periosteal new bone formation. This is a patient with the chronic recurrent multifocal osteomyelitis (CRMO). In early stages of disease plain radiograph is normal. MRI is more sensitive, shows marrow changes and subtle synovial enhancement. An MRI skeletal survey is recommended as a preferred follow-up modality in patients with established disease, a role previously done by the bone scan

Case 40

This is an adult with a shoulder injury.

Not particularly challenging diagnosis. Obvious observation is a shoulder dislocation. Humeral head is very low in relation to the acromion/acromioclavicular joint, indicating significant disruption of the supporting ligaments. Do you see anything else? A calcific element is seen in the region of joint space. This is actually a part of the fracture of the greater tuberosity. This is unlikely to be ligamentous calcification.

Case 41

10-month-old child had a history of minor fall a few months ago, presently limping.

Often we come across some interesting radiographs in the child. This radiograph looks bizarre. Obviously there is a deformity of the distal femoral metaphysis. Looks like malunited fracture. Essentially there is malalignment, areas of sclerosis, cortical remodeling and the solid periosteal bone formation. Epiphysis is visualized, grossly appearing normal. The bones appear to show coarse trabecular pattern and some minor bending. Muscles appear to have undergone some amount of atrophy. Combinations of these findings are seen in patients with nutritional rickets complicated by a fracture. There may be abundant osteoid, not fully calcified. Alignment abnormalities are very frequent.

Case 42

This is a 5-year-old child with joint deformity. With this case I would like to bring out some classical old descriptions regarding bone changes in chronic childhood arthropathies. What you are seeing, essentially, is enlarged epiphyses and part of the metaphysis of long bones showing osteopenia and coarse trabecular pattern. There is joint swelling with mild fullness in the suprapatellar region. This appearance is unlikely due to local conditions like enchondroma or similar focal bone disease. This used to be the common appearance in the past, in patients with Still’s disease (juvenile rheumatoid arthritis) and in patients with haemophilia with recurrent joint haemorrhage. This patient did not have haemoglobinopathy. When more than one joint is involved diagnosis of still’s disease is easier. Obviously this needs complete laboratory evaluation. I do not have the complete followup in this patient hence the discussion is conjectural.

Case 43

17-year-old patient with a painful foot while prolonged walking. Frontal and lateral radiographs of the foot and ankle region are provided.

What is your impression on the radiographs provided? Earlier in the presentation, I had shown a case of apparent tarsal fusion. Now we are seeing a real case of tarsal fusion. On the right side you can see navicular bone, cuboid and cuneiforms well outlined. On the left side there is a bony fusion between navicular bone and the cuneiforms. All the 3 cuneiforms appear to have fused as well. Cuboid is relatively large; this is a classic case of navicular-cuneiform fusion. Did you think the right side is absolutely normal?  It was normal as far as the navicular and cuneiforms are concerned. But there is an abnormality of talus, which shows unusual bulky configuration with a shallow head. Also note that there is an adductus deformity of the metatarsals.

Case 44

Series of radiographs of an infant with breathing difficulty are provided. This infant has a clinical chest deformity and short stature. Chest radiographs demonstrate short ribs, hardly reaching 50% of AP diameter, leading to small thoracic cavity. The iliac wings are small and squared, with flattened acetabular roofs, narrow sacro-sciatic notches, and prominent spikes at the medial and lateral acetabular margins. There is variable limb shortening with metaphysis showing irregularity and mild widening. The clavicles demonstrate a “handlebar” appearance. The hands and and feet. demonstrate mild shortening of metatcarpals, metatarsals, and phalanges.

Diagnosis is rather straightforward, if you are aware of this entity. We are dealing with a patient of Asphyxiating thoracic dystrophy (ATD); Jejune syndrome

Following conditions has some overlapping features, can be entertained in the differential consideration 

• Short rib polydactyly, type III (probably an allelic variant of ATD)

• Ellis-van Creveld syndrome (chondroectodermal dysplasia)

• Metaphyseal chondrodysplasia with exocrine pancreatic insufficiency (Schwachman-Diamond syndrome)

There are many skeletal dysplasia's with respiratory insufficiency, small thoracic cavity, and shortening of ribs. The most common is ATD (Jeune syndrome), an autosomal recessive condition first described by Jejune, Presentations vary. Severely affected newborns may die of respiratory insufficiency soon after birth, whereas other patients survive the neonatal period often develop renal insufficiency later in life due to a concomitant cystic renal dysplasia. The incidence of ATD is 1 in 100,000 to 130,000 live births.

Case 45

I assume that you have observed dense metaphyseal lines in femora and tibia. This finding may reflect a systemic disease or involvement. Conditions leading to this findings are:

Common Causes:

• chronic anemia, e.g. sickle cell disease, thalassemia

• chemotherapy, e.g. methotrexate

• growth acceleration lines following growth arrest due to systemic illness or stress in infancy or childhood, e.g. asthma, diabetes, cystic fibrosis, juvenile chronic arthritis, juvenile rheumatoid arthritis, malnutrition

• lead poisoning

• leukemia: treated

• normal variant: especially in a neonate - dense zone of provisional calcification

• renal osteodystrophy (secondary hyperparathyroidism): healing

• rickets: healing

• trauma: non-accidental injury; stress fracture

Other entities are rare, following are the conditions

• aminopterin fetopathy

• bisphosphonate therapy

• chronic recurrent multifocal osteomyelitis

• congenital transplacental infection, e.g. toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis

• deprivation (psychosocial) dwarfism with trauma

• drug or hormone therapy in high dosage, e.g. steroids, parathyroid hormone, methotrexate, estrogen or heavy metal therapy to the mother during pregnancy

• dysosteosclerosis

• other heavy metal or chemical poisoning, e.g. bismuth, arsenic, phosphorus, fluoride, mercury, lithium, radium, Thorotrast

• hypervitaminosis D

• hypoparathyroidism/pseudohypoparathyroidism

• hypothyroidism: cretinism (treated)

• meconium peritonitis (neonatal dense bands)

• metaphyseal chondrodysplasia(s)

• osteopetrosis

• oxalosis

• parathyroid hormone therapy

• Patterson syndrome

• radiation injury from bone-seeking isotopes (strontium-90, yttrium-90, phosphorus-32)

• sclerosteosis: especially knees

• scurvy: healing

• spondyloepimetaphyseal dysplasia(s)

• spondylometaphyseal dysplasia(s)

• vascular injury

• Williams syndrome: idiopathic hypercalcemia

(Source: Radiopedia)

Case 46

Infants with short stature, cranio-facial abnormality with polydactyly, promptly reminds us Ellis-van creveld syndrome.( also called chondroectodermal dysplasia). The patients usually present clinically by facial characteristics, congenital heart disease, post axial polydactyly and abnormal hair or nails in addition to the radiographic findings of mesomelic dwarfism. Our patient has facial hypoplasia with microcephaly. Other noted features are 'S' shaped bilateral clavicles, shortened upper and lower extremities. Medial spurs at bilateral proximal tibial metaphysis seen. Long bones show medial concavity, metaphyseal widening with salient mesomelic involvement. There are tibia varus deformity seen. Bilateral six metacarpal digits seen.  The sixth digits are seen at the medial aspects of the hands consistent with bilateral post-axial polydactyly.( Details partly obscured due to hand positioning)  Patient had congenital heart disease, ASD. Some differential  considerations include Asphyxiating thoracic dystrophy ( Jeune syndrome) , Short-rib polydactyly syndrome and Familial polydactyly

Case 47

This case is more like a spotter. Two benign entities are seen together - not a frequent occurrence. There is a pedunculated exostosis and an non-ossifying fibroma. Pathologically both entities are different. Both can present with a syndromic form with multiple ares of involvement and other association like skin lesions, growth disturbances, soft tissue tumors etc. Jaffe Campinassi syndrome and Hereditary diaphyseal eclasis are the examples.

Case 48

Radiography of the perinatally dead infant provides detailed information about the skeleton and is a valuable as an adjunct to autopsy .For evaluation of both the axial and appendicular skeleton, it is necessary to obtain two exposures in the AP plane, one dedicated to the axial skeleton and one (approximately 10 kV less) to the extremities. An additional lateral view of the axial skeleton is required. The fetus should be positioned straight, with the arms and legs extended and fixed with adhesive tape, and the head supported in neutral position. The fetus should be placed directly on the film to minimize magnification caused by the diverging X-ray beam 

MRI has been employed and is currently being extensively evaluated as an alternative to fetal autopsy. Preliminary results are promising, and one would anticipate that with further technical development MRI may become a diagnostically acceptable alternative to autopsy.

Regarding post-natal fetal radiography, whole body radiography remains an important diagnostic supplement to the perinatal autopsy. Radiologists play a key role in identifying constitutional disorders of bone and lethal syndromes with skeletal manifestations. Among perinatally dead infants, estimates of gestational age both by ultrasound and by the calendar methods are systematically erroneous. Estimates by the calendar method should generally be preferred since ultrasound measurements are highly influenced by fetal growth restriction. If available, early first-trimester and, preferably repeated, ultrasound measurements probably provide the most accurate estimate. References for length of individual bones and presence of secondary ossification centers are suggested. These should be used to identify disproportionate skeletal growth stage, but not to estimate fetal gestational age. 

[Source: Ø. E. Olsen (2006) Radiography Following Perinatal Death: A Review, Acta Radiologica, 47:1, 91-99, DOI: 10.1080/02841850500406811 ]

Case 49

Skeletal survey of a child with short stature and neck deformity is provided. Child has normal mental developments

Skull radiograph; AP and lateral view shows dolichocephalic skull configuration, frontal bossing and J-shaped sella. AP radiograph of both hands, and wrists shows metaphyseal expansion of long bones with planes of both the distal ulnar and radial growth plates seen slanted toward each other. Conical (bullet-shaped) proximal parts of 2–5 metacarpals with normal construction of metacarpal shafts and tapering of the proximal phalanges are seen. The ossified carpal bones are small and reduced in number for the patient's age. X-ray of cervical spine shows loss of lordosis and C1-C2 dislocation. Serial radiographs show minimal instability. Vertebral bodies show anterior tapering and end-plate irregularities.. Patient also had mild kyphoscoliosis and multi-level vertebra plana with central anterior beaking. Ribs show broadening of the anterior portion (tongue shape) Radiograph of the pelvis and both femurs typically reveal flared iliac bones with inferior constriction (wine-glass shape). Enlarged shallow acetabular cavities with deformed femoral epiphyses and widened femoral necks. Most important element in the disease is C1-C2 subluxation, which may progress leading to neurological deficit. Surgical stabilization may be needed.

Morquio syndrome (MS) (mucopolysaccharidoses Type IV [MPS IV]) is a member of a group of inherited metabolic disorders collectively termed MPS. Morquio, a pediatrician and Brailsford, a Radiologist simultaneously described cases of MS. Hurler coined the term dysostosis multiplex to describe the constellation of skeletal findings specific to patients with MPS and other lysosomal storage disorders. Patients with MS can be clinically distinguished from other forms of MPS in that their intelligence is unimpaired. The diagnosis can be made based on the physical, radiological features, blood enzymes, and skin biopsy. 

Case 50

I hope you are able to appreciate the abnormality in left talus. There is an osteolytic lesion with minimal sclerosis, joint fluid and soft tissue swelling. Rest of the bones are normal. Such appearance is common in osteomyelitis. It could either pyogenic( acute presentation) ot sub-acute chronic ( Tubercular/Fungal ). Since involvement is in the flat bone, immune state of the child need to be investigated. CRMO shows changes in the joint and multiple joint involvement. For exclusion of multifocal involvement Tc 99 bone scan can be done .MRI skeletal screening os a good alternative. This patient had acute osteomyelitis due to a pyogenic organism. Patient responded completely.

Case 51

I have shown you an example of this disease earlier. Here we see osteopenic bones with fractures, Bones are slender. Large head, open fontanelle wide sutures and wormian bone are seen. We are dealing with Osteogenesis imperfecta. Previous morphological classification included thin and thick bone variety. Classification was also done on the basis of onset of clinical presentation. Now disease is classified on genetic basis. Other observation like, fragile lax skin, muscle hypotonia and blue sclera may be present. There is increased incidence of hernia.

Case 52

This skeletal survey illustrates one of the best known sclerotic  bone disorder.( Osteopetrosis) Patients can have autosomal recessive and dominant  trait. There is failure to resorb primitive  bone  in the marrow due to a defect in the osteoclasts. Resultant defect leads to accumulation of primitive bone- in the medulla, appearing on imaging as a sclerotic bone. Axial and appendicular skeleton is affected. There is loss of corticomedullary demarcation in bone. Occasionally defective bone formation is intermittent, leading to alternating ares of normal and dense bone. Large head with sclerotic skull base, modeling abnormalities of long bones and hepatosplenomegaly are seen, Well known radiological findings are Rugger Jursey spine, bone within a bone appearance and zebra skin sign. Despite dense appearance, bones are brittle. Transverse fractures, spondylolysis are often seen. Disease is also known as Albers-Schönberg disease or marble bone disease,

There are two separate subtypes of osteopetrosis:

• infantile autosomal recessive osteopetrosis

• benign adult autosomal dominant osteopetrosis

There are well known syndromic associations. One such cluster is associated with intracranial calcification, Findings of osteopetrosis may be seen with imaging findings of cleido-cranial dysostosis. The condition is called Pycnodysostosis.

Case 56 

This middle-aged patient with the knee joint pain and swelling underwent plain radiography. Plain film observation lead to a straightforward diagnosis of synovial osteochondromatosis [ aka  Joint osteo-chondramatosis, synovial chondromataplasia]. Multiple well corticated rounded radiopacities are generally seen, some of them showing a radiolucent centre. This is can be monoarticular or polyarticular. Knee, hips and elbow are affected frequently. Such changes can be also seen in extra-articular location around the tendons. There is a male predominance. Appearance of these lesions on MR characteristic, almost reminiscent of pigment stones in the gallbladder. There are two presentations

1. primary synovial chondromatosis: predominantly monoarticular disorder of unknown etiology

2. secondary synovial chondromatosis: resulting in intra-articular loose bodies from causes such as trauma, osteoarthrosis and neuropathic arthropathy. Second variety is due to metaplasia of synovium due to chronic irritation.

(Source Pathology outlines and Radiopedia)

Some differential diagnosis can be considered if findings are not typical. Entities include cartilaginous close bodies, lipoma arborescens, pigmented villonodular synovitis tumoural calcinosis. And vascular malformations

Case 57

This 5 yr child presented to the hospital following trauma with the swelling in the posterior aspect of the knee. Child was not able to walk. MRI examination was preceded by sonographic examination. You can see that there is joint fluid which appears to be more localised to the proximal part of the knee joint on the posterior aspect. Fluid appears to have low level internal echoes and some echogenic areas? Clots. There is extensive oedema of the muscles. Popliteal vessels were patent.

MR examination revealed more striking observation in the form of the focal joint capsular bulge, disruption along the posterior aspect. Posterior joint capsule is ill-defined. There is a joint fluid and extensive oedema of the proximal attachment of the head of gastrocnemius. PCL appears intact, ACL not clearly shown. There was a suspicion of a detachment of menisco-tibial ligament. There is no evidence of bony injury. This form of injury is seen in hyperextension of the knee. Patient was managed conservatively. I do not have long-term followup of this patient. It would be interesting to evaluate the joint stability.

A diagrammatic anatomic illustration of the posterior aspect of the knee joint is provided.MR observation posterior joint capsule disruption with a regional haematoma was diagnosed. 

Fig. 5. —Line drawing in transverse plane illustrates relationships of posterior capsule. Superficially (1, arrowheads), structures of popliteal fossa are covered by superficial fascia. Deep in relation to fascia, medial (mg) and lateral (lg) gastrocnemius muscles can be seen, as well as biceps muscle (b) and semimembranosus (Sm) and semitendinosus (St) tendons. Second layer (2, arrow) can be seen posteromedially and posterolaterally. At level of posteromedial and posterolateral corners, this layer is intimately fused with synovial layer (3, arrows). At intercondylar area, synovium separates from capsule and covers cruciate ligaments (AC, PC, arrowheads). Lateral collateral ligament (LCL) can be seen in close proximity to posterolateral capsule.

https://www.ajronline.org/doi/pdf/10.2214/ajr.182.4.1820955

Case 58

Radiographs of the ankle and distal leg are provided in multiple views. Patient was evaluated for persistent pain. Obvious appearance of osteopenia is present in the distal Tibia and fibula as well as in the tarsal bones. Do you see anything else of importance?  Perhaps some radiolucencies and linear,transverse radio opaque lines are noted in the distal metaphysis of the tibia? Growth disturbance lines. Patient underwent an MR examination in view of persistent symptoms. Now what is your impression? We see a bandlike area of T1 hypo intensity with STIR hyperintensity at the distal tibia. Similar changes are also noted in the posterior aspect of the tibial metaphysis at the interface with the epiphyseal plate. These findings are consistent with the stress injury. Patient was treated conservatively and showed recovery. The appearance is unlike that of osteomyelitis, which is predominantly a marrow disease, not eccentric as seen in our patient. Typical locations of stress injury are the second metatarsal bone, (soldiers’ fracture or march fracture) tibial shin and proximal medial cortex of tibia. Patient with osteomalacia are also prone for similar fractures in the pelvic girdle, ribs and the scapula.

Case 59

This is an infant, 7 weeks old, observed not to move the left lower limb. Initial sonography revealed the minimal hip joint fluid. Subsequently an MR examination was performed. Once you go through the set of MR images you will notice that there is an area of osteolysis involving the left femoral head. Then there is a joint fluid and enhancing synovium in the postcontrast studies. Enhancement is also noted around the joint capsule in the surrounding tissue planes. Bone change in the femoral head is well defined and shows a small amount of peripheral sclerosis. In this instance a diagnosis of osteomyelitis with septic arthritis was made. Joint aspirate grew fungus. No bacterial growth was obtained. Osteomyelitis, in this age group often due to a gram-positive organism, subsequently extending to joint space in some instances.(Tom-Smith). This infant had a normal immune profile. Unfortunately, I do not have the long-term follow up on this patient.

 Case 60

Adult patient with seizures and radiography of the extremity was performed. As the clinical context is suggesting a scrutiny for soft tissue calcification, we need to look carefully. Am sure you will be able to fish out 'rice grain' calcification. This patient had cysticercosis. This patient also had a small subcutaneous nodule on the medial aspect of the proximal leg on the left side. Sonography of the superficial nodules can be performed for more details. However, most of the cases are detected incidentally.

Case 61

An 8-year-old child who presented with limping and the left hip pain was investigated with plain radiography. Certainly, there is an osteolytic lesion in the proximal femur located in the central part of the shaft. Margins are well-defined, not sclerotic. Laterally lesion appear to be breaking through the cortex. And there is a bubbly/multilocular appearance. There is no soft tissue swelling or evidence of new bone formation. These features can be seen in simple bone cyst, although bone cyst tends to be often unilocular, showing slight bone expansion and sclerotic margin. In this patient the differential diagnosis should include infective pathology like tuberculosis and eosinophilic granuloma. The other body parts like legs and skull were evaluated. What do you think about the metaphyseal lesion of the left femur? Is it related to the proximal femoral lesion? Well, this lesion appears to be a fibrous defect, showing sclerotic margin. Skull lesion however could be due to eosinophilic granuloma. In the skull a 'bone within bone' appearance can be seen due to differential scalloped margins of the inner and outer table. Lytic lesions may undergo reparative process and sclerosis leading to near complete healing. This disease comes under the broad category of histiocytosis X.  Langerhans Cell Histiocytosis (LCH) is an entity presenting in infancy to adolescence with the skin changes, bone changes of differing severity and other systemic manifestation. Hand Schuller Christian complex is a childhood manifestation with predominant single location lesion presence. Letterer-Siwe disease is seen in infancy with extensive bone disease, organomegaly and lymphadenopathy. In both instances bone changes are more extensive; systemic manifestations and organomegaly are common, compared to EG. Classical individual organ systems are described with interesting imaging features.  Typical locations are CNS, pulmonary, hepatobiliary, and skeletal.

Case 62

Frontal and oblique view of the pelvis is provided in a patient with a history of injury. CT has taken a frontline position in the evaluation of skeletal trauma. Hence the need to interpret the plain film has reduced. In the provided frontal view of the pelvis do you have any evidence of injury? Perhaps you have to guess a lot. Due to overlapping bowel gas/artefacts injury to the flat bone is difficult to assess. Occasionally oblique/tangential views will help, as shown in this example. Subtle break in the discontinuity of the cortex is better shown in the oblique view.

Case 63

Elderly patient with bone pains. You are provided with a plain radiograph and some images of the skull. Bed side x-rays are a challenge for interpretation. Generally, bedside radiography has a specific purpose for requesting such examinations. While interpretation, additional observations, if present, are often overlooked. I want you to look carefully at this patient's bedside chest view.. Do you see any bony abnormalities? There are subtle lytic lesions in the visualized scapula. They are also present in the clavicle, though not obvious. This patient underwent a CT examination of the brain. When we look at the bone window, we notice subtle areas of radiolucency in the skull. Findings are visible in the scout view as well as in the coronal reconstructions. There are punched out diploic lesions with the erosion of the underlying cortex. Margin of the lytic lesion is ill-defined, differentiating them from arachnoid granulations or venous lakes. This patient has had multiple myeloma with systemic involvement.

Case 64

36-year-old patient with a slowly growing soft tissue swelling in the medial end of left clavicle. You have been provided with a chest radiograph and axial CT sections. With the clinical history provided, what can you suspect on CX. An ill-defined haziness in the medial part of the left upper zone. No additional observations are noted. In the CT images, (soft tissue and bone window), you can appreciate a lobulated soft tissue mass anterior to the medial aspect of the left clavicle. Lesion is homogeneous with subtle contrast enhancement and focal areas of calcification at the anterior aspect. There is remodeling and sclerosis of the clavicle at the point of contact with the lesion. Scalloped bony appearance suggests an unlikely origin of lesion from the bone. Differential diagnosis of such lesions as many like desmoid tumors, neurofibroma, mesenchymal masses, synovial sarcoma and fibrous histiocytoma etc. Do you see anything else in this patient? This patient has a right aortic arch with the aberrant left subclavian artery.

Case 65 : 

Our patient is a young boy with neckpain and rigidity. Scanogram is of limited value, shows a cervical kyphus and soft tissue swelling. Sagittal and parasagittal CT reconstructions show an interesting vertebral  lesion.Which vertebra/vertebrae  is most abnormal ? If you sort this out, you will make a diagnosis. It is like solving a murder mistry. My bet was on C4, which shows vertebra plana appearance. Then posterior componets are disorganised with maked proliferative sclerotic elements. Adjecent vertebrae also show abnormal posterior elements. C3 and C5 vertebral bodies show sclerosis. Spinal canal was occupied by exophytic bony elements. There was no sizeble soft tisse componets.  What possibilities can be considered in this context? 1. Aneurysmal bone cyst  2. Osteoblastoma 3. Osteosarcoma and 4. Gaint cell tumour probobly will be on the top of the list. This patient underwent spinal decompression. Biopsy revealed an osteoblastoma. Spinal immobilisation was done.

Case 66

This is an extremely interesting entity. 46-year-old male patient presents with the stiffness and limitation of hip movements.

CT non-contrast images and some reconstructions are provided. What do you think is likely pathology? It is very evident that there is extensive calcification in the iliac bone and upper femur. Is it myositis ossificans? Is it a result of fracture? Or is it due to some rare disorders like dermatomyositis?  

Initial impression on this examination was that of myositis ossificans.  It could be a long-standing case of myositis ossificans. But I do see certain features which are slightly different. If you carefully note the regional bone contours are surrounded by this mass like areas of calcification. Subsequently we see the thin muscles at the periphery. Most of the calcium observed is in relation to the outer margins of the bone, hence most of the calcification is subperiosteal or parosteal in location. So probably we are dealing with a periosteal disease which has resulted in the extensive surrounding calcification. Perhaps we had to dig into the mechanisms and possibilities which can lead to such an entity. Trauma certainly can be a compounding element.

Case 70

Radiographs of the pelvis and lower extremities of the child are presented. Child had a talipes equinovarus deformity and the joint hyperextensibility. 

You will notice that in this case visualised bones appear nearly normal. Important thing is to observe abnormal alignment of the joints and deformities. In this case it is manifested as hyperextension of the knee joint and the rectus equinovarus deformity of the feet. Pelvic girdle appears normal. This patient had arthrogryposis. 

This condition also goes by the name arthrogryposis multiplex congenita. This involves the 2 or more joint deformities at birth. Diagnosis is made by clinical evaluation; occasionally other studies like nerve conduction studies, electromyography and muscle biopsy are needed to exclude other causes of deformity.. Skeletal surveys for bony morphology are often done. MR imaging of the CNS may be necessary to exclude intracranial causes.

Case 71

An 8-year-old child with a painful knee was evaluated with plain radiography. In a young child painful gait or limp requires radiography of the lower limb with the pelvic girdle included. Often the strategy was to identify disease which is clinically not detected. If more precise localization is possible, radiography should be limited to the area of interest, including the proximal and distal joints.

Did you see any abnormality in our patient? This is one of the testing moments for radiologists who are involved in trauma reporting. Radiographs of the knee joint demonstrate subtle changes of epiphyseolysis on the right side. Minor changes of widening of epiphyseal plate noted in the frontal view, although not conclusive. Lateral view clearly demonstrates a widened epiphyseal plate with the very unequivocal changes in the posterior part. If you are not sure, comparison with the contralateral knee (included) is a conclusive proof. Prompt detection is very critical in type I Salter-Harris injuries. If not detected complete displacement may take place. Diaphragmatic illustration of the types of Salter-Harris injury is provided.

Case 72

This 12-year-old child had pain from the hand movements with inability to flex the index finger.

Plain radiography and MRI examinations are provided. I hope you have noticed a subtle expansion and ill-defined radiolucency involving the distal aspect of the second metacarpal bone. If you are a careful observer, you will also notice that the joint space is reduced with the soft tissue swelling around. There is an early solid periosteal reaction. Now look at the MRI examination. There is more conclusive evidence in the form of marrow oedema involving the head of the second metacarpal bone , adjacent shaft and part of the proximal phalanx. There is a slight malalignment of the joint with suggestion of minimal joint fluid. The bony margins are indistinct on both sides of the metacarpophalangeal joint. Other T2 and STIR images show extensive oedema of the bone and others and soft tissues. We will also notice fluid in the tendon of the flexor digitorum indicis. All the findings are in favour of septic arthritis of the metacarpophalangeal joint of the index finger with adjacent osteomyelitis. This is a very rare presentation in which a child's immune status must be evaluated to exclude a predisposing status. Sometimes tuberculosis of the joint presents with a similar appearance.

Case 73

Case 74

This 9-year-old child with the nagging type pain while playing was investigated with plain radiography. I am showing this case, as there are any investigations done in this patient, some of them are redundant. This patient shows a classical appearance of the sessile exostosis of the femoral shaft. Appearance and location of the lesion is somewhat bizarre in the frontal view. However, in the lateral view findings are typical. CT evaluation in this case was redundant although striking 3D views are presented. MR evaluation probably is much more appropriate to evaluate soft tissues as well as the thickness of cartilage cap. Another investigation that was performed in this patient is a bone scan–not a usually performed modality for this diagnosis. Radionuclide examination does show areas of increased uptake, indicating there is bone turnover. This information is important as it indicates a possible growth potential.

Case 76

A 5-year-old child with a painful elbow was evaluated with plain radiography. You have sets of examinations, one for the right elbow and an additional set with both elbows.

Interpretation of the elbow is a challenge in young children. Have a look at the radiographs and see whether you notice any abnormality. I have not provided any information as to which joint is clinically suspected. You can make your guess and attempt a diagnosis 

Well, to be fair enough I had to reveal that the left elbow is painful. Is there a bony injury? Clue to this question comes from the knowledge of chronology of the ossification center and its sequence. If you carefully observe, you  will notice that the ossification center of the medial epicondyle is not in position. On scrutiny you will notice it very close to the proximal ulna. This is an avulsion injury of the ossification center of medial epicondyle. Comparison with contralateral elbow is helpful in confirming the diagnosis in borderline cases. This injury also goes by the name Little Leaguer's elbow, pattern of ball throwing injury

Case 77

Radiographs of lower limb bones in a child with short stature and a stiff joint is presented.

What is the most striking observation after going through the radiograph? I believe in this patient we see abnormal epiphysis. The ossification centers of the long bones show irregularity of outline, some fragmentation and the asymmetry of growth. This is a manifestation of an epiphyseal syndrome. This may be associated with additional bony changes. In this patient the long bones show minimal bowing and shortening. The diaphyseal and soft long bones show some abnormalities of tabulation. Surrounding soft tissues are essentially appearing normal. In this patient a spinal evaluation was unremarkable, an area where additional observation can be seen in some syndromes.

This is a syndrome goes by the name of multiple epiphyseal dysplasia or dysplasia epiphysealis multiplex or fairblank disease. It is a autosomal dominant disease with some characteristic findings in the epiphysis, double layer patella and delayed growth.

As a broad category epiphyseal dysplasias can be considered in the following groups:

1. isolated epiphyseal abnormality without platyspondyly ( chondrodysplasia punctata group)

2. concomitant involvement of spine (platyspondyly) (spondyloepiphyseal dysplasia congenita and tarda, Kniest dysplasia and achondrogenesis type 2; 

3. concomitant metaphyseal involvement ( spondylo(epi)metaphyseal dysplasias, multiple epiphyseal dysplasia, pseudoachondroplasia, mucopolysaccharidoses, diastrophic dysplasia and achondrogenesis type 1)

Well described findings of the multiple epiphyseal dysplasia (MED) are

1) Bilateral and symmetric involvement of epiphyses of hips, knees, ankles, shoulders, elbows, wrists and hands and feet

 (2) Lateral tibio-talar slant wherein the lateral part of distal tibial epiphyses is thinner than the medial and the trochlea of the talus is shaped to conform to the abnormal ankle joint mortise

(3) Double-layered patella in the lateral view is supposed to be pathognomonic. However this observation may be seen in pseudoachondroplasia as both EMD1 and pseudoachondroplasia are caused due to mutations affecting the same COMP gene

(4) Mild involvement of spine with anterior wedging, mild endplate irregularity and multiple Schmorl’s nodes mimicking Scheuermann’s disease and typical absence of platyspondyly.

Patient did not have double layer patella as the ossification centre was not developed. Also the spine was within normal limits.

( Panda A, Gamanagatti S, Jana M, Gupta AK. Skeletal dysplasias: A radiographic approach and review of common non-lethal skeletal dysplasias. World J Radiol. 2014;6(10):808-825. doi:10.4329/wjr.v6.i10.808) 

Case 78 

Evaluation of cervical spine, shoulders and dorsal spine of an 8-year-old child with the short stature and abnormal shoulder is provided. I hope that you are able to make a diagnosis in this case based on given radiographs.

Cervical spine frontal and lateral views show block vertebra at C4/5 level and C6/7 levels. The changes at 6-7 are more advanced, with loss of disc space and fusion of posterior elements. Craniovertebral junction appears normal. Fusion of vertebral lateral components are better shown on the frontal view with some defective spinous processes. There are bilateral rudimentary cervical ribs. Now the shoulder views. Note that the left shoulder is higher with an abnormal orientation of the scapula which is winged. –Almost horizontally oriented. The clavicle also appears somewhat broad. While the shoulder joints appear normal, there are multiple rib anomalies. With these 2 combinations you should be able to make a diagnosis of Klippel-Feil syndrome.

By the way did you look for an Omo-vertebral bone?  While looking for this notice that the scapular margin is almost adjacent to the transverse process, perhaps with a fibrous connection between scapula and the posterior spinal elements. Additionally, there is an evaluation of the dorsal spine which shows loss of height at multiple vertebrae, an additional observation in the disease.

Klippel-Feil syndrome clinically presents with the triad of short neck, low hairline, and restricted neck motion in half of the patients. There are many other associated lesions.

Associations

• Sprengel deformity of the shoulder 

• Duane syndrome

• anomalies of the aortic arch and branching vessels, e.g. carotid, subclavian arteries

• spinal scoliosis, spinal cord anomalies,

• intervertebral disc herniation .cervical spondylosis 

• renal abnormalities, e.g. unilateral renal agenesis

According to the original classification of Klippel-Feil, 3 categories are described.

• type I: fusion of many cervical and upper thoracic vertebrae

• type II: fusion of two or three vertebrae with associated hemivertebrae, occipito-atlantal fusion or other cervical spine abnormalities

• type III: cervical fusion with lower thoracic or lumbar vertebral fusion

(Radiopedia)

Case 79

10-year-old child with multiple joint swelling, deformity, and pain. Skeletal survey is performed. I intend this case to be a nidus for imaging evaluation of syndromes. Certainly, you will notice that there are bony abnormalities in the feet, knees, to a lesser extent hands. Also note that there is a soft tissue component. I will revisit observations in a different sitting.

Case 82 : 40-yr-adult with painful limitation of shoulder abduction.

Case 82

Multiple MRI images of a young patient with the limitation of abduction is presented. Generally fluid sensitive sequences provide most clues regarding soft tissue abnormality. T1 sequences give greater anatomic information and subtle marrow signal abnormality. The radiology residents should be able to identify all the sequences and basic technical parameters.

Now in this case you can make an observation and final diagnosis. Most striking observation is abnormal abnormality of the rotator cuff which looks thin, partly discontinuous and shows high T2 signal. There is some fluid in the subcoracoid as well as subacromial bursa. Marrow signals of the bony component of the shoulder joint appear normal. Hearing dealing with a partial tear in the rotator cuff with fluid around the bursa. Sagittal images should be carefully analysed to look at the maximum abnormality in the rotator cuff. In the patient more anterior parts are affected compared to the posterior.

Anatomic location of the tear can be at the insertion, at the critical zone or myo-tendinous insertion. Classification of subtype are as follows (Radiopedia)

A modification of the original Codman classification may be used to categorize tears:

• full-thickness rotator cuff tear 

  • massive rotator cuff tear, Fosbury flop tear

• partial-thickness rotator cuff tear

  • ​intrasubstance tear: not in communication with the joint surface or with the bursal surface of the tendon 

  • articular-sided tear

    • rim rent tear: articular surface tear of the footprint

    • with tendon delamination or interstitial tear, if the gap is filled with fluid, then it is called cleavage tear of the rotator cuff

  • bursal-sided tear

Ultrasound when performed well has up to 90% sensitivity and specificity. It can also reveal other mimics like tendinosis, calcific tendinitis, subacromial-subdeltoid bursitis, greater tuberosity fracture, and adhesive capsulitis.

Case 83

A 12-year-old child with a history of trauma and limping is evaluated with an MR examination. 

This is a simple example of a MR examination of the knee, demonstrating straightforward observations. If you serially go through those images, you will notice an area of marrow oedema in the region of tibial tubercle. This observation should make you suspect an injury to the anterior cruciate ligament or its inferior attachment. Ligament itself is not visible. Posterior cruciate ligament is visualized, rather lax. Another subtle observation is that the cortical interface of the upper tibia in the region of the anterior tubercle is lost. There is no joint fluid, and the soft tissues appear normal. Finally, the diagnosis of avulsion injury to the anterior tibial tubercle with the injury to the anterior cruciate ligament is likely diagnosis

Case 86

Clusters of radiographs of extremity are provided. This collage of radiographs is intended to demonstrate the common appearance of bony injury in extremities. (A) wrist injury involving the distal radius and ulna, including articular surface. Evaluation should also include the assessment of alignment of the carpal bones in a true lateral view. (B) Is there a fracture in this patient? This patient demonstrated a plastic fracture of the radius and ulna, characterized by excessive bowing. (C) this patient demonstrated an impacted fracture of proximal metaphysis seen as areas of radiolucency and sclerosis. (D) Where is the fracture in this patient?  Calcaneal fractures can be subtle. Although in this case injury is obvious, it also involves the articular part. Minor calcaneal injury can be seen as an area of abrupt trabecular disruption. (E) What is the nature of injury here? This is an avulsion injury of the lateral condyle ossification center. (F) Is there a fracture in this patient? Normal variation at times mimics subtle fractures. This patient did have an undisplaced fracture of the acromion process. Minor diastasis of the acromioclavicular junction is suspected. This observation should be verified by comparison with the other AC joint.

Case 87: 31-yr-old with spinal deformity since birth

Case 88: 19-yr-old male,known case of thalassemia, BMT and multiple transfusions

Case 89: 20-yr-male with right shoulder pain

Case 90   (Old case 1990, digitised photographs)

A 14-year-old female presented with the painful acute onset of swelling of her shoulder. There was no history of trauma. Sonographic examination revealed predominantly hypoechoic intramuscular swelling along the medial scapula. Subsequent plain radiograph was unremarkable. CT evaluation of the region demonstrated a soft tissue swelling with heterogenous hypodense change in the posterior chest wall, medial to the scapula, fat planes of the paraspinal muscles are distorted. Patient underwent surgical decompression of the lesion which revealed a hematoma.  

Spontaneous intramuscular hematomas are well known. Most frequent site is a rectus sheath. They may be associated with the following strenuous exercise or acute stretching in a traumatic setting.  Most frequent are minor trauma, increasedigitised photographd abdominal pressure (sneezing, straining, coughing, gagging), anticoagulation medications, hypertension, and iatrogenic causes (e.g., intramuscular injections or laparoscopic surgery). Elderly patients and patients on anticoagulation are frequently affected. Prognosis is good.