Age dependent T2 changes of bone marrow in pediatric wrist MRI

Pediatric Wrist

Pediatric wrist injuries pose unique diagnostic challenges due to distinct bone characteristics in children and their diverse injury patterns. The dynamic development of the wrist, marked by changes in bone age and emerging ossification centers, is crucial to evaluate growth and identify potential pathologies. The skeletal composition, rich in cartilage, renders bones relatively weaker yet more elastic, impacting their susceptibility to fracture. Forearm fractures display diverse patterns influenced by torsional forces. Scaphoid fractures, less common in children, differ from those in adults. Conditions like Madelung's deformity and ulnar variance are more common wrist disorders in the pediatric population. In addition, the scarcity and nonspecificity of symptoms in those with tendon injuries and triangular fibrocartilage complex lesions can be diagnostically challenging. This article reviews pediatric wrist injuries, emphasizing ossification patterns, common fracture types, and developmental variants. Grasping these complexities in pediatric wrist development and associated pathologies is essential for precise diagnosis and treatment.

Dual-Energy Computed Tomography-Based Quantitative Bone Marrow Imaging in Non-Hematooncological Subjects: Associations with Age, Gender and Other Variables

Background: Our aim is to assess the utility and associations of quantitative bone marrow attenuation (BMA) values measured on clinical dual-energy computed tomography (DECT) exams in non-hematooncologic subjects with skeletal regions, patient age, gender, and other clinical variables. Methods: Our local ethics committee approved this retrospective image data analysis. Between July 2019 and July 2021, 332 eligible patients (mean age, 64 ± 18 years; female, 135) were identified. Inclusion criteria were the availability of a standardized abdominopelvic DECT data set acquired on the same scanner with identical protocol. Eleven regions-of-interest were placed in the T11-L5 vertebral bodies, dorsal iliac crests, and femur necks. Patient age, gender, weight, clinical, habitual variables, inflammation markers, and anemia were documented in all cases. Results: Multi-regression analyses (all, p < 0.05) identified age as the strongest predictor of lumbar BMA (standardized coefficient: β = −0.74), followed by CRP (β = 0.11), LDH (β = 0.11), and gender (β = −0.10). In the lower thoracic spine, age was the strongest predictor (β = −0.58) of BMA, followed by gender (β = −0.09) and LDH (β = 0.12). In femoral bones, age was negatively predictive of BMA (β = −0.12), whereas LDH and anemia were positively predictive (β = 0.16 both). Heart insufficiency significantly decreased (β = 0.12, p = 0.034) a BMA value gradient from higher to lower HU values along the vertebrae T11 and L5, whereas age significantly increased this gradient (β = −0.2, p ≤ 0.001). Conclusions: DECT-based BMA measurements can be obtained from clinical CT exams. BMA values are negatively associated with patient age and influenced by gender, anemia, and inflammatory markers.

Diagnostic accuracy of imaging approaches for early tumor detection in children with Li-Fraumeni syndrome

BACKGROUND

The Toronto protocol for cancer surveillance in children with Li-Fraumeni syndrome has been adopted worldwide.

OBJECTIVE

To assess the diagnostic accuracy of the imaging used in this protocol.

MATERIALS AND METHODS

We conducted a blinded retrospective review of imaging modalities in 31 pediatric patients. We compared imaging findings with the reference standards, which consisted of (1) histopathological diagnosis, (2) corresponding dedicated imaging or subsequent surveillance imaging or (3) clinical outcomes. We individually analyzed each modality's diagnostic performance for cancer detection and assessed it on a per-study basis for chest and abdominal regional whole-body MRI (n=115 each), brain MRI (n=101) and abdominal/pelvic US (n=292), and on a per-lesion basis for skeleton/soft tissues on whole-body MRI (n=140).

RESULTS

Of 763 studies/lesions, approximately 80% had reference standards that identified 4 (0.7%) true-positive, 523 (85.3%) true-negative, 5 (0.8%) false-positive, 3 (0.5%) false-negative and 78 (12.7%) indeterminate results. There were 3 true-positives on whole-body MRI and 1 true-positive on brain MRI as well as 3 false-negatives on whole-body MRI. Sensitivities and specificities of tumor diagnosis using a worst-case scenario analysis were, respectively, 40.0% (95% confidence interval [CI]: 7.3%, 83.0%) and 38.2% (95% CI: 29.2%, 48.0%) for skeleton/soft tissues on whole-body MRI; sensitivity non-available and 97.8% (95% CI: 91.4%, 99.6%) for chest regional whole-body MRI; 100.0% (95% CI: 5.5%, 100.0%) and 96.8% (95% CI: 90.2%, 99.2%) for abdominal regional whole-body MRI; sensitivity non-available and 98.3% (95% CI: 95.3, 99.4) for abdominal/pelvic US; and 50.0% (95% CI: 2.7%, 97.3%) and 93.8% (95% CI: 85.6%, 97.7%) for brain MRI.

CONCLUSION

Considerations for optimizing imaging protocol, defining criteria for abnormalities, developing a structured reporting system, and practicing consensus double-reading may enhance the diagnostic accuracy for tumor surveillance.

Edema-like marrow signal intensity: a narrative review with a pictorial essay

The term edema-like marrow signal intensity (ELMSI) represents a general term describing an area of abnormal signal intensity at MRI. Its appearance includes absence of clear margins and the possibility of exceeding well-defined anatomical borders (for example, physeal scars). We can define "ELMSI with unknown cause" an entity where the characteristic MR appearance is associated with the absence of specific signs of an underlying condition. However, it is more often an important finding indicating the presence of an underlying disease, and we describe this case as "ELMSI with known cause." It presents a dynamic behavior and its evolution can largely vary. It initially corresponds to an acute inflammatory response with edema, before being variably replaced by more permanent marrow remodeling changes such as fibrosis or myxomatous connective tissue that can occur over time. It is important to study ELMSI variations over time in order to evaluate the activity state and therapeutic response of an inflammatory chronic joint disease, the resolution of a trauma, and the severity of an osteoarthritis. We propose a narrative review of the literature dealing with various subjects about this challenging topic that is imaging, temporal evolution, etiology, differential diagnoses, and possible organization, together with a pictorial essay.

How We Manage Bone Marrow Edema-An Interdisciplinary Approach

Bone marrow edema (BME) is a descriptive term for a common finding in magnetic resonance imaging (MRI). Although pain is the major symptom, BME differs in terms of its causal mechanisms, underlying disease, as well as treatment and prognosis. This complexity together with the lack of evidence-based guidelines, frequently makes the identification of underlying conditions and its management a major challenge. Unnecessary multiple consultations and delays in diagnosis as well as therapy indicate a need for interdisciplinary clinical recommendations. Therefore, an interdisciplinary task force was set up within our large osteology center consisting of specialists from internal medicine, endocrinology/diabetology, hematology/oncology, orthopedics, pediatrics, physical medicine, radiology, rheumatology, and trauma surgery to develop a consenus paper. After review of literature, review of practical experiences (expert opinion), and determination of consensus findings, an overview and an algorithm were developed with concise summaries of relevant aspects of the respective underlying disease including diagnostic measures, clinical features, differential diagnosis and treatment of BME. Together, our single-center consensus review on the management of BME may help improve the quality of care for these patients.

Review article: the differential diagnosis of bone marrow edema on wrist MRI

There is a large variety of conditions that can result in 'bone marrow edema' or 'bone marrow lesions' (BML) in the wrist on magnetic resonance imaging (MRI). The combination of clinical history and the distribution of the BML can serve as a valuable clue to a specific diagnosis. This article illustrates the different patterns of BML in the wrist to serve as a useful guide when reviewing wrist MRI studies. Imaging artefacts will also be briefly covered.

MRI shows a high incidence of carpal fractures in children with posttraumatic radial-sided wrist tenderness

Background and purpose - The epidemiology and optimal diagnostics of wrist injuries in children are not knotwn. We describe fractures revealed by magnetic resonance imaging (MRI) in a prospective population of children and adolescents with posttraumatic radial-sided wrist tenderness, and compare the diagnostic value of radiographs and computed tomography (CT) with that of MRI. Patients and methods - From 2004 to 2007, patients less than 18 years of age who presented at our emergency department were included in the study. 90 wrists in 89 patients underwent clinical, radiographic, and low-field MRI investigation. If plain radiographs or MRI revealed a scaphoid fracture, a supplementary CT scan was performed. Sensitivity and specificity of radiographs and CT for diagnosis of scaphoid fractures was calculated using MRI as the reference standard. Results - 74 fractures were diagnosed in 61 of 90 wrists using MRI; 48 wrists had a scaphoid fracture, 8 had a distal radius fracture, 7 had a capitate fracture, and 3 had a triquetrum fracture. The most common combination of fractures was scaphoid and capitate. The sensitivity of radiographs for visualization of scaphoid fractures was 54% and the specificity was 100%. The sensitivity for other fractures was <50%. The sensitivity of CT for visualization of scaphoid fractures was 96% and it was between 33% and 100% for other fractures. Interpretation - MRI showed a high incidence of fractures in children and adolescents with posttraumatic radial wrist tenderness, and it led to the diagnosis of more fractures than plain radiographs and CT. A scaphoid fracture was the most common carpal injury, followed by fracture of the capitate.

Tibial stress changes in new combat recruits for special forces: patterns and timing at MR imaging

PURPOSE

To characterize the incidence, location, grade, and patterns of magnetic resonance (MR) imaging findings in the tibia in asymptomatic recruits before and after 4-month basic training and to investigate whether MR imaging parameters correlated with pretraining activity levels or with future symptomatic injury.

MATERIALS AND METHODS

This study was approved by three institutional review boards and was conducted in compliance with HIPAA requirements. Volunteers were included in the study after they signed informed consent forms. MR imaging of the tibia of 55 men entering the Israeli Special Forces was performed on recruitment day and after basic training. Ten recruits who did not perform vigorous self-training prior to and during service served as control subjects. MR imaging studies in all recruits were evaluated for presence, type, length, and location of bone stress changes in the tibia. Anthropometric measurements and activity history data were collected. Relationships between bone stress changes, physical activity, and clinical findings and between lesion size and progression were analyzed.

RESULTS

Bone stress changes were seen in 35 of 55 recruits (in 26 recruits at time 0 and in nine recruits after basic training). Most bone stress changes consisted of endosteal marrow edema. Approximately 50% of bone stress changes occurred between the middle and distal thirds of the tibia. Lesion size at time 0 had significant correlation with progression. All endosteal findings smaller than 100 mm resolved or did not change, while most findings larger than 100 mm progressed. Of 10 control subjects, one had bone stress changes at time 0, and one had bone stress changes at 4 months.

CONCLUSION

Most tibial bone stress changes occurred before basic training, were usually endosteal, occurred between the middle and distal thirds of the tibia, were smaller than 100 mm, and did not progress. These findings are presumed to represent normal bone remodeling.

Imaging in juvenile idiopathic arthritis (JIA): an update with particular emphasis on MRI

Juvenile idiopathic arthritis (JIA) is a heterogeneous condition encompassing all forms of chronic arthritis of unknown origin and with onset before 16 years of age. During the last decade new, potent therapeutic agents have become available, underscoring the need for accurate monitoring of therapeutic response on both disease activity and structural damage to the joint. However, so far, treatment efficacy is based on clinical ground only, although clinical parameters are poor markers for disease activity and progression of structural damage. Not so for rheumatoid arthritis patients where the inclusion of radiographic assessment has been required by FDA to test the disease-modifying potential of new anti-rheumatic drugs. In imaging of children with JIA there has been a shift from traditional radiography towards newer techniques such as ultrasound and MRI, however without proper evaluation of their accuracy and validity. We here summarize present knowledge and discuss future challenges in imaging children with JIA.

MRI assessment of bone marrow in children with juvenile idiopathic arthritis: intra- and inter-observer variability

BACKGROUND

Bone marrow oedema (BMO) is included in MRI-based scoring systems of disease activity in adults with rheumatoid arthritis. Similar systems in juvenile idiopathic arthritis (JIA) are lacking.

OBJECTIVE

To assess the reproducibility in a multi-centre setting of an MRI BMO scoring system in children with JIA.

MATERIALS AND METHODS

Seventy-six wrist MRIs were read twice, independently, by two experienced paediatric radiologists. BMO was defined as ill-defined lesions within the trabecular bone, returning high and low signal on T2- and T1-weighted images respectively, with or without contrast enhancement. BMO extension was scored for each of 14 bones at the wrist from 0 (none) to 3 (extensive).

RESULTS

The intra-observer agreement was moderate to excellent, with weighted kappa ranging from 0.85 to 1.0 and 0.49 to 1.0 (readers 1 and 2 respectively), while the inter-observer agreement ranged from 0.41 to 0.79. The intra- and inter-observer intraclass correlation coefficients were excellent and satisfactory, respectively.

CONCLUSION

The scoring system was reliable and may be used for grading bone marrow abnormality in JIA. The relatively large variability in aggregate scores, particularly between readers, underscores the need for thorough standardisation.

MRI appearance of presumed self-inflicted trauma in the knees of military recruits

When knee bone marrow edema is observed on magnetic resonance imaging (MRI), it usually follows a pattern that can be explained by certain etiologies. This article describes a series of unusual knee bone marrow edemas in soldiers presumed to represent self-inflicted trauma.Ten soldiers (9 men and 1 woman; age range, 19-24 years) underwent knee MRI. None reported recent trauma or stress, and all presented with nonspecific pain or failure to respond to therapy. All showed a similar unusual pattern of bone marrow edema in the medial femoral condyle. Three observers evaluated the location of the bone marrow edema within the medial femoral condyle and its distance from the articular surface, dimensions, overlying soft tissue abnormality, and internal derangements. The edema was always subcortical and located in the middle aspect (n=7) or mid-anterior aspect (n=3) of the medial femoral condyle but was never centered subarticularly. Edema size ranged between 8 × 10 × 8 and 32 × 46 × 40 mm. Overlying soft tissue abnormalities were common (n=4) and included organizing (n=1) and residual hematoma (n=3). Concomitant MRI abnormalities were seen in 3 patients, usually minor. Eight patients reported longstanding pain with no antecedent trauma, and 2 reported remote trauma. One patient had a negative 4-month follow-up MRI, and another had a negative arthroscopy. Poor correlation existed between MRI findings and the absence of stress and trauma. Soldier chat rooms were found that describe how to induce fractures at this location.

Pediatric cervical spine marrow T2 hyperintensity: a systematic analysis

OBJECTIVE

Hyperintense areas of vertebral bone marrow on fluid-sensitive sequences are at times seen on pediatric MRI of the cervical spine in children without suspicious clinical conditions to explain marrow pathology. Although these likely have no clinical significance they may be mistaken for pathology. The purpose of this study is to systematically evaluate the locations and patterns of marrow T2 hyperintensity in the pediatric cervical spine, with respect to age.

MATERIALS AND METHODS

At 1.5 T, the C2 through T3 vertebrae of 82 children aged 0-17 years without clinically suspicious marrow abnormality were retrospectively reviewed by two musculoskeletal radiologists, who were blinded to patients' age. The frequency, intensity, and location of the foci of marrow T2 hyperintensity were recorded for each vertebra on a 12-point scoring system and were correlated with the patients' age.

RESULTS

Foci of marrow hyperintensity were seen in 46/82 (56.1%) patients and in 241/734 (32.8%) vertebrae. Foci were most common in C4 (42% of patients), C5 (45.7%), and C6 (37.8%). The foci of T2 hyperintensity were more common inferiorly (188 foci) and adjacent to the anterior cortex (123). Analysis revealed no significant correlation between age and marrow score (Spearman = -0.147, P = 0.19), but did find a trend towards increased presence of marrow T2 hyperintensity in the ages of most rapid growth, 8-14 years (81.5% of patients).

CONCLUSION

Vertebral body marrow T2 hyperintensity was most common endosteally and in the mid-cervical spine with a slight peak in adolescence. We therefore believe that these pediatric cervical marrow changes may be related to rapid bone growth at the point of maximal kyphotic stress.