An infant presents with lethargy, frontal bossing and bowing of legs. X-ray shows widening of epiphysis. What is the diagnosis?
Ref: Nelson's Textbook of Pediatrics, 19th edition, Page 205Explanation:RICKETSClinical FeaturesGeneralo Failure to thriveo Listlessnesso Protruding abdomeno Muscle weakness (especially proximal)o Fractures.Heado Craniotabeso Frontal bossingo Delayed fontanel closureo Delayed dentitiono Craniosynostosis.Chesto Rachitic rosaryo Harrison groove.o Respiratory infections and atelectasis.Backo Scoliosiso Kyphosiso Lordosis.Extremitieso Enlargement of wrists and ankleso Valgus or varus deformitieso Windswept deformity (combination of valgus deformity of 1 leg with varus deformity of the other leg).o Anterior bowing of the tibia and femuro Coxa vara,o Leg pain.Hypocalcemic symptomso Tetanyo Seizures.o Stridor due to laryngeal spasm. Radiological FeaturesRachitic changes are most easily visualized on X-ray wrist.Decreased calcification leads to thickening of the growth plate.Fraying - The edge of the metaphvsis loses its sharp border.Cupping - The edge of the metaphysis changes from a convex or flat surface to a more concave surface, which is easily seen at the distal ends of the radius, ulna and fibula.Coarse trabeculation of the diaphysis.Generalized rarefaction.Increased distance between epiphysis to metaphysis.Figure: Active ricketsRADIOGRAPHIC CHANGES IN SCURVYThe typical changes occur at distal ends of the long bones and are particularly common at the knees.The shafts of the long bones have a ground- glass appearance due to trabecular atrophy.The cortex is thin and dense, giving the appearance of pencil outlining of the diaphysis and epiphysis (Pencil thin cortex).The white line of Frankel. an irregular but thickened white line at the metaphysis, represents the zone of well-calcified cartilage.The epiphyseal centers of ossification also have a ground-glass appearance and are surrounded by a sclerotic ring.The more specific but late radiologic feature of scurvy is a zone of rarefaction under the white line at the metaphysis. This zone of rarefaction (Trumerfeld zone), a linear break in the bone that is proximal and parallel to the w hite line, represents area of debris of broken- down bone trabeculae and connective tissue.A Pelkan spur is a lateral prolongation of the white line and may he present at cortical ends. Epiphyseal separation can occur along the line of destruction, with either linear displacement or compression of the epiphysis against the shaft.Subperiosteal hemorrhages are not visible using plain radiographs during the active phase of scurvy. However, during healing the elevated periosteum becomes calcified and radiopaque, giving a dumbbell or club shape to the affected bone.
Scurvy
Rickets
Osteomalacia
Osteopetrosis
Metabolic Disorders