A review of the actual knowledge of the processes governing growth and development of long bones

Autoptic samples of human bones (from 8 weeks of gestation to 12 years of age) and a second group of serial, skeletal x-rays (required for pathologies not related to bone dysplasia in children from 4 months to 17 years of age) provided the material for the analysis of the physes normal growth mechanism presented in this review. Before the appearance of the ossification centers epiphyseal growth rests exclusively on chondrocytes proliferation (interstitial growth), without any detectable differentiated cellular organization. When endochondral ossification starts a defined spatial disposition of chondrocytes and a corresponding organization of the intercellular matrix is set up, so that it is possible to identify a growth vector corresponding to the columns of piled chondrocytes with direction from hypertrophic toward the proliferative cell layers. The complexity of the tubular bones growth process is well represented by the spatial arrangement of the growth vectors. In the late epiphyseal growth another mechanism is active in addition to endochondral ossification, namely, articular cartilage interstitial growth and subchondral remodelling. The knowledge of the normal mode of organization of the physis and its temporal sequence can help to better understand of the deviaton from the normal development of metaphyseal and epiphyseal dysplasias.

Fetal akinesia deformation sequence. Case report

A patient with a rare congenital lethal skeletal dysplasia characterised by thin gracile bones and fractures secondary to a neuromuscular disease is reported. This disease has to be differentiated with other thin, gracile bone disorders.

Congenital aggressive variant of Langerhans cells histiocytosis with CD56+/E-Cadherin- phenotype

In children < 2 years of age, cutaneous involvement is the most frequent presentation of Langerhans cell histiocytosis (LCH). Cutaneous LCH can be localized or associated with dissemination and organ dysfunction. The clinical course is variable, ranging from spontaneous regression to a fatal outcome. We describe a female newborn presenting with congenital cutaneous lesions who rapidly developed pulmonary infiltrates and multiple osteolytic lesions. Skin biopsy showed a dermal infiltrate of medium to large cells morphologically and phenotypically consistent with LCH. The clinical course was rapidly fatal in spite of chemotherapy. No strict correlation between morphology and prognosis has been documented in LCH, but, in our case, distinct morphological and immunohistochemical features (CD56 expression and no E-Cadherin expression) may have contributed to an aggressive clinical course.

Air embolism in the newborn: rare complication of intensive care therapy in children

Systemic air embolism in neonates, either premature or full term, necessitating mechanical ventilation is a devastating and usually fatal condition. We describe three cases of this complication, two in mechanically assisted preterm babies, and one in a full-term dysmorphic patient. Causes and possible management are described.

Intervertebral disc calcifications in children

PURPOSE

This study was done to assess the presence of both asymptomatic and symptomatic intervertebral disc calcifications in a large paediatric population.

MATERIALS AND METHODS

We retrospectively reviewed the radiographs taken during the past 26 years in children (age 0-18 years) undergoing imaging of the spine or of other body segments in which the spine was adequately depicted, to determine possible intervertebral disc calcifications. The following clinical evaluation was extrapolated from the patients' charts: presence of spinal symptoms, history of trauma, suspected or clinically evident scoliosis, suspected or clinically evident syndromes, bone dysplasias, and pre- or postoperative chest or abdominal X-rays.

RESULTS

We detected intervertebral disc calcifications in six patients only. Five calcifications were asymptomatic (one newborn baby with Patau syndrome; three patients studied to rule out scoliosis, hypochondroplasia and syndromic traits; one for dyspnoea due to sunflower seeds inhalation). Only one was symptomatic, with acute neck pain. Calcifications varied in number from one in one patient to two to five in the others.

CONCLUSIONS

Apart from the calcification in the patient with cervical pain, all calcifications were asymptomatic and constituted an incidental finding (particularly those detected at the thoracic level in the patient studied for sunflower-seed inhalation). Calcification shapes were either linear or round. Our series confirms that intervertebral disc calcifications are a rare finding in childhood and should not be a source of concern: symptomatic calcifications tend to regress spontaneously within a short time with or without therapy and immobilisation, whereas asymptomatic calcifications may last for years but disappear before the age of 20 years. Only very few cases, such as those of medullary compression or severe dysphagia due to anterior herniation of cervical discs, may require surgical procedures.

An unusual form of spondyloepiphyseal dysplasia, with advanced carpal and spinal end-plate ossification mimicking COMP-mutation-like multiple epiphyseal dysplasia

We present a child with irregular ossification of tubular bone epiphyses, short bones, and spine. The radiographic evolution of bones undergoing endochondral ossification was followed from the age of 1 year 9 months to 6 years. The unusual features demonstrated in this child made classification difficult: pseudoachondroplasia was excluded because no mutations of the COMP gene were found. Considering the evolution of the radiographic appearances, the most likely diagnosis would seem to be an unusual form of spondyloepiphyseal dysplasia, mimicking some aspects of multiple epiphyseal dysplasia. Endochondral ossification was diffusely altered with a mixture of epiphyseal ossification delay associated with acceleration and early fusion. This case was a unique presentation within the family, suggesting a mutation in the affected child.

Spinal osteomyelitis due to Aspergillus flavus in a child: a rare complication after haematopoietic stem cell transplantation

We report the case of a child affected by acute myeloid leukaemia who was treated with allogeneic haematopoietic stem cell transplantation and developed cervicothoracic spinal osteomyelitis due to Aspergillus flavus. The diagnosis was difficult on a clinical basis, but made possible by conventional radiography and MRI.

Poly-epiphyseal overgrowth: description of a previously unreported skeletal dysplasia

A skeletal dysplasia with previously unreported features is presented. Its evolution was characterized by growth abnormalities of bones without involvement of other organs. Advanced bone age, increased stature and irregular epiphyseal ossification with stippling of the main long bones were documented. Physeal overgrowth was massive in the left proximal humerus and femur. Furthermore, the hip joint appeared fused with an abundant mass of pathological calcific tissue extending from the femur to the ilium. Pathological epiphyses were characterized by anarchic cartilaginous proliferation with multiple ossification centres, while lamellar bone apposition and remodelling were normal. The observed bone changes were different from those in any previously reported syndrome, metabolic defect or bone dysplasia. However, they clearly indicated a defect of endochondral ossification with some resemblance to phenotypes observed in dysplasia epiphysealis hemimelica.

Bone malformations in Proteus syndrome: an analysis of bone structural changes and their evolution during growth

The radiographic follow-up of a patient with Proteus syndrome is presented. Review of radiographs obtained at 3 years 10 months, 10 years, and 17 years 8 months indicated that the rate of growth in length of the oversized tubular bones of the hands was similar to that of the normal bones of the same hand. This observation supports the view that the primary lesion occurs in the early embryonic period, when the limb bud mesenchyme cells condense and cartilage differentiates producing oversized cartilage anlages, rather than being a defect of bone cell-mediated apposition and modelling processes of bone. Additional radiographs of the pelvis and spine were obtained at age 4 years 10 months and head CT at 8 years 10 months. This pathogenetic mechanism fits well with the hypothesis of somatic mosaicism, which is at present the most credible explanation for the aetiology of Proteus syndrome. Other skeletal malformations recognized as typical of the syndrome can be interpreted as secondary adaptations to the altered mechanical conditions induced by overgrowth of bones.

Cowper's glands and ducts: radiological findings in children

PURPOSE

The aim of this study was to describe the radiological features of simple or dilated (syringocele) Cowper's ducts in a large paediatric population.

MATERIALS AND METHODS

Voiding cystourethrography procedures performed during the past 24 years were evaluated taking into special account urethral morphology. The procedures were performed to study all sorts of possible urinary affections.

RESULTS

A total of 1,676 male children (age: newborn to 18 years) underwent 2,340 voiding cystourethrographies. Opacification of Cowper's ducts was observed in nine children (0.53%) - in six (0.35%) as a thin, radiopaque image running parallel to the inferior edge of the membranous-bulbar urethra and in three (0.18%) as a dilated structure (syringocele); this was a source of significant voiding problems.

CONCLUSIONS

Opacification of Cowper's ducts - even if rare - has to be recognised as a possible anatomical finding during voiding cystourethrography in paediatric patients. An accessory finding devoid of pathological meaning in most cases, it can, however, be a possible cause of voiding disorders in some instances.

Clinical and radiological findings in Kirner’s deformity. A report of nine cases

PURPOSE

The purpose of this study is to report radiological findings and evaluate the frequency with which Kirner's deformity is found in a large paediatric population.

MATERIALS AND METHODS

We reviewed X-ray films of the hands taken over the past 23.5 years in order to assess not only bone age but all sorts of bone abnormalities (trauma, haematological disorders, bone syndromes and dysplasias, dysmorphic features, rheumatic disorders, etc.) to retrospectively evaluate all those presenting Kirner's deformity.

RESULTS

Among the 16,326 patients who underwent X-ray study of the hands, nine (six males and three females, 0.055% of the total) presented the typical radiological features of Kirner's deformity; no patient had a family history of the disorder except for one, in whom the suspicion of familiarity could not be verified radiologically. The diagnosis of Kirner's deformity was straightforward in most cases. In one case, a girl affected by Turner's syndrome, the abnormality was suspected, and its appearance, development and evolution was followed over 10 years.

CONCLUSIONS

Although rare, as also shown by our study, Kirner's deformity must be recognised and properly diagnosed in order to spare the subject unnecessary surgical procedures.

Urethral polyp in a 1-month-old child

Urethral polyps are a rare finding in children, particularly in the very young. They are suspected by the presence of various clinical signs such as obstruction, voiding dysfunction and haematuria. There is an association with other urinary tract congenital anomalies. They are usually benign fibro-epithelial lesions with no tendency to recur and are treated by surgical ablation, fulguration or laser therapy. We report a 1-month-old boy with an antenatally diagnosed left ectopic pelvic kidney, postnatal urinary tract infection and no clinical signs of obstruction. Voiding cystourethrography to exclude vesico-ureteric reflux showed a trabeculated bladder and a mobile filling defect in the posterior urethra. Owing to its large size, cystotomy was necessary to remove the polyp successfully.

Angel-shaped phalanges in brachydactyly C: a case report, and speculation on pathogenesis

We describe a woman and her daughter affected by brachydactyly type C. The unusual feature in the child included the striking 'angel-shaped' appearance of the proximal phalanges of the index and middle fingers of one hand, whereas more typical triangular epiphyses with elongation of their radial side were present at the same location in the opposite hand. It is suggested that this peculiar phalangeal configuration occurs as a transitory event in early or mid childhood in phalanges that are marked by severe ossification delay, which is most prominent at the level of the primary ossification centre.

Jejunal intussusception in a 10-year-old boy with blue rubber bleb nevus syndrome

Jejunal intussusception in a Chinese 10-year-old boy affected by the blue rubber bleb nevus syndrome is presented and discussed. The syndrome is rare, sporadically found with possible dominant inheritance, and due to a gene mutation mapped on the short arm of chromosome 9. It presents with distinctive cutaneous and gastrointestinal malformations together with possible other organ involvement. Gastrointestinal malformations tend to bleed and lead to anaemia. Infrequent complications of the gastrointestinal malformations are volvulus, intestinal infarction and intussusception. The age of the patient and the jejunal intussusception precipitated by a vascular malformation containing calcifications (which were also found in different gut segments) make this case remarkable.

Growth hormone deficiency, anorectal agenesis, and brachycamptodactyly: A phenotype overlapping Stratton-Parker syndrome

Stratton and Parker [1989] described a 17-month-old boy with the previously unreported combination of growth hormone (GH) deficiency, Wormian bones, mild developmental delay, brachycamptodactyly, heart defects, kidney hypoplasia, imperforate anus, bilateral cryptorchidism, and facial anomalies. A similar case was later reported by Gabrielli et al. [1994], who suggested the existence of a "Stratton-Parker syndrome." Here, we describe a boy with isolated GH deficiency, body asymmetry, and brachycamptodactyly. At birth, complete anorectal agenesis and cryptorchidism were detected, which required surgical treatment. Radiographic examination showed the presence of bilateral proximal radioulnar subluxation and Kirner anomaly. Brain MRI showed asymmetry of the posterior horns of the lateral ventricles and enlarged cisterna magna. Psychomotor development had been mildly delayed during the first years of life. Due to the unique association of GH deficiency with intestinal, genital, and limbs abnormalities, we believe that our patient may represent a further case of Stratton-Parker syndrome. All patients reported, till date, are sporadic males born to healthy nonconsanguineous parents. X-linked recessive inheritance is a possibility to consider.