It is estimated that the ratio between the femoral and tibial growths is 0.94/0.67 (1.4), but the accuracy of the data used to obtain it is limited. We aim to find a correlation between the rate of new bone growth in between each zebra line in the patients with Osteogenesis Imperfects (OI) who have received cyclic bisphosphonate (BP) therapy with each treatment cycle between the distal tibia and proximal femur. This will allow us to quantify the growth of the distal femur and proximal tibia with accuracy. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Tokaria Rumana, Jaramillo Diego

Keywords: Osteogenesis Imperfecta, zebra lines, growth rate

In adults, the terms <b><i>osteopenia</i></b> and <b><i>osteoporosis</i></b> are used to describe different severities of diminished bone density which can result from a variety of causes. The World Health Organization has defined osteopenia as decreased bone density corresponding to a bone densitometry T-score of -1 to -2.5 and osteoporosis as a more severe deficiency (T score &gt; -2.5). However, the etiology usually is not apparent on radiographs of skeletally mature patients. Osteopenia and osteoporosis are used regardless of the etiology of apparent decreased bone density. In contradistinction to the ambiguity inherent in adult radiographs, in growing children, the distinctly different etiologies and corresponding histopathologic abnormalities that result in diminished radiographic bone density can be differentiated, thanks to clues offered by the open physis. Disorders that manifest as rickets (the equivalent to adult osteomalacia) result from the decreased ability to deposit calcium hydroxyapatite on a normal amount of osteoid. This causes disruption of endochondral ossification at the physis and results in apparent physeal widening with loss of the zone of provisional calcification. Alternatively, disorders that cause osteoporosis result from diminished osteoid available for subsequent mineralization, show prominent zones of provisional calcification, and are without rickets-like changes. This educational exhibit will begin with a review of the steps of normal endochondral and intramembranous ossification, followed by a discussion of the pathophysiology of osteomalacia and osteoporosis. Upon this foundation, we will illustrate various etiologies that result in either rickets/osteomalacia or osteoporosis. Finally, we will present the imaging clues that lead to a diagnosis and to the corresponding correct terminology. This use of precise language cannot be stressed enough, as it has important clinical implications. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Boehnke Mitchell, Jaramillo Diego, Laor Tal

Keywords: Osteoporosis, Osteomalacia, Physis

Prior to maturity, a secondary physis surrounding the patella defines an area of potential weakness. We seek to understand how age, sex, and physeal status affect the prevalence and degree of patellar osteochondral injury and medial patellofemoral ligament (MPFL) injury after acute patellar dislocation. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Varada Sowmya, Wong Tony, Jaramillo Diego

Keywords: patella, osteochondral injury, MRI

Subcutaneous fat necrosis of the newborn (SCFN) is an uncommon disorder predominantly occurring in full-term and post-term neonates during the first 6 weeks of life. Clinically it presents as an area of edema followed by indurated plaques or non-tender and mobile nodules with overlying erythema, typically along the back, buttocks, extremities, or cheeks. SCFN may result from localized tissue hypoxia and mechanical pressure that further compromises the local circulation. Fetal and neonatal conditions including macrosomia, perinatal asphyxia, traumatic birth and therapeutic hypothermia; and several maternal conditions including preeclampsia, hypertension, gestational diabetes, cocaine or cigarette exposure, calcium channel blocker use during pregnancy, and familial dyslipidemia have been associated with SCFN. Although SCFN is a self-limiting condition, patients should be monitored for associated hypercalcemia and its complications such as nephrocalcinosis and nephrolithiasis. As these lesions are superficial, they are well evaluated with high resolution ultrasound imaging for initial assessment and follow-up. Findings on ultrasound and MRI include lesions confined to the subcutaneous fat sparing the dermis, with indistinct borders lacking a distinct mass. Lesions of SCFN are echogenic on US, intermediate to low signal intensity on T1-weighted sequences, intermediate to high signal on fluid sensitive sequences, and may demonstrate cystic changes. We will review the imaging findings of subcutaneous fat necrosis in over ten newborns collected from three tertiary care hospitals, with a focus on ultrasound findings. Many of the lesions were multifocal and the majority involved the patient's back. Ultrasound evaluation was performed in all cases. MRI performed in a minority of cases will also be reviewed. While only one case was biopsied for pathologic correlation, each lesion was closely followed clinically. We will also review several mimickers of fat necrosis to be aware of. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Fenlon Edward, Jaramillo Diego, Restrepo Ricardo, Corral Gonzalo

Keywords: Ultrasound, Fat, Necrosis

Post-Transplant Lymphoproliferative Disease (PTLD) is a polyclonal and monoclonal lymphoid proliferation which occurs in 1-20% of solid organ transplant recipients. It is most common in multivisceral organ transplants followed by small bowel transplants, heart and lung transplants and less commonly in liver and kidney transplants. PTLD has a bimodal distribution of occurrence with the largest peak occurring within 1 year after transplantation and a second peak at approximately 4-5 years after transplantation. The Epstein Barr virus (EBV) is associated in 50-70% of cases. EBV seronegativity in the recipient at the time of transplant predicts a 2-4 times increased risk of PTLD especially if they receive a donor organ which is positive for EBV. This may explain the higher incidence in the pediatric population who tend to be seronegative for EBV. The World Health Organization (WHO) identifies four pathologic categories of PTLD: early lesions, polymorphic type, monomorphic type and classic Hodgkins lymphoma. The majority of PTLD cases are caused by B-lymphocyte proliferation in a T-cell depleted environment in the setting of immunosuppression. However, there is a subset of cases that are caused by T-cell or natural killer cells as well as cases that occur in the setting of negative EBV. Multiple clones of proliferating B-cells can be seen in a single patient. 2/3 of cases have diffuse expression of CD20 which is an important target for therapy. PTLD may be focal or diffuse and can manifest in a variety of different organ systems or even in the allograft itself. There is a higher percentage of extranodal disease in PTLD as compared to immunocompetent patients with lymphoma. The GI tract and liver are most commonly involved. Isolated lymph node involvement in comparison is less common in patients with PTLD. Central nervous system (CNS) involvement is relatively rare in PTLD. This educational exhibit will provide a pictorial review of PTLD and illustrates cases from one of the busiest transplant centers in North America to highlight the major imaging findings as well as complications seen on imaging of this disease. Extranodal and nodal disease will be demonstrated on multiple modalities as well as complications of this disease including intussusception and biliary obstruction. CNS disease will also be shown. The clinical manifestations, imaging characteristics, prognosis and treatment will be discussed and depicted. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Maddocks Alexis, Fenlon Edward, Chen Susie, Ruzal-shapiro Carrie, Jaramillo Diego

Keywords: PTLD

Proximal humeral epiphyseal fracture-separation is a rare fracture pattern in infants often associated with birth-related or non-accidental trauma, representing a Salter-Harris type I or type II fracture. Lack of a proximal humeral epiphyseal ossification center in most newborns or only subtle displacement of a small epiphyseal ossification center in older infants, makes this injury difficult to diagnose on plain radiographs, potentially leading to delayed diagnosis or misdiagnosis. Ultrasound and MRI are therefore useful imaging modalities in indeterminate cases. Clinical findings of infant proximal humeral epiphyseal fracture-separation such as shoulder swelling, tenderness, and decreased active motion, overlap with more common entities including clavicular fracture, brachial plexus injury and osteomyelitis. Radiographs are often the first diagnostic study ordered to evaluate these symptoms but are insensitive due to minimal ossification of the proximal humeral epiphysis. Radiographs may be normal or show subtle displacement of the epiphyseal ossification center, apparent joint space widening, small metaphyseal fracture fragments or displacement of the proximal humeral metaphysis in relation to the scapula. These findings can be misdiagnosed as shoulder dislocation or pseudosubluxation due to a joint effusion. Careful review of the medical record may elucidate a history of difficult delivery with shoulder dystocia or suspected shoulder trauma. Ultrasound and MRI are useful in indeterminate cases due to their ability to resolve the cartilaginous physis and proximal humeral epiphysis, and to resolve their relationship to the humeral shaft and cartilaginous labrum. Ultrasound has higher anatomic resolution and offers the flexibility to quickly image the asymptomatic contralateral shoulder and image in planes that best show the relationship between the non-ossified epiphysis and the humeral shaft. Doppler ultrasound demonstrates epiphyseal perfusion without the need for contrast administration, and serial ultrasound imaging can be used to evaluate healing and remodeling. MRI is more useful in evaluating cases where osteomyelitis and/or septic arthritis are being considered, or in cases of an inconclusive history suspicious for non-accidental trauma to evaluate for additional osseous and soft tissue injuries. Several examples of typical proximal humeral epiphyseal fracture-separations in infants will be presented and the relevant imaging findings discussed. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Fenlon Edward, Degnan Andrew, Maddocks Alexis, Chen Susie, Jaramillo Diego

Keywords: Fracture, Infant, Trauma

Chronic nonbacterial osteomyelitis (CNO) is an aseptic auto-inflammatory condition that affects children and presents with insidious bone pain. Children present with a variable clinical spectrum of disease with either unifocal or multifocal pain and acute (duration &lt; 6months) or chronic (&gt;6 months) symptoms. The disease course may be recurrent. In some cases, patients endure multiple lesions over a course of exacerbations and remissions. Bone lesions are often in symmetrical regions. Interestingly, clinically asymptomatic bone lesions are discovered during the imaging evaluation. Patient symptoms and clinical course may mimic other diseases, making CNO often difficult to diagnose with a consequent delay in diagnosis. Children with CNO may also develop arthritis and demonstrate similar cytokine profiles with children with juvenile idiopathic arthritis (JIA), suggesting at least a partial common disease pathway. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Mowrer Gregory, Jaramillo Diego, Restrepo Ricardo, Imundo Lisa, Flemming Don, Chauvin Nancy

Keywords: chronic nonbacterial osteomyelitis, osteitis, CRMO

Diffusion tensor imaging (DTI) depicts the anisotropic motion of water molecules limited by tissue microstructure. Images of tractography provide qualitative information about complex tissue architecture, so that diffusion metrics reflect physeal activity. DTI’s main clinical application is on brain white matter, but it can be used in any tissue in which there is organized tissue structure. Our research group has used tractography of the knee to study the structure of the physis and adjacent metaphysis and investigated the potential of DTI metrics as biomarkers predictive of skeletal growth. DTI parameters include tract count, tract length and tract volume and fractional anisotropy (FA). They can help distinguish between a normal and a dysfunctional physis, predict post-imaging growth and physeal closure, and possibly determine response to growth hormone treatment. We will demonstrate the techniques for data acquisition, preprocessing, and analysis, and the basis for interpretation, based on our experience of performing DTI in over 900 knees. Each step has its own challenges for the standardization and optimization of DTI of the physis. The goal of this poster is to showcase our experience with the establishment of an efficient DTI pipeline. We will: 1) Discuss the impact of variation of DTI acquisition parameters (e.g. Time to Echo (TE), number of directions, b-value, voxel size…); 2) Describe programs for distortion correction and denoising , as well as the required post-processing software programs; 3) Discuss approaches to standardize the acquisition in the different anatomic areas and cross vendors; 4) Discuss the normal change of tractography data and physeal DTI metrics with age, sex and specific knee physis. We will show how DTI changes due to physeal dysfunction in different pathologies, such as growth hormone deficiency, trauma, arthritis, metabolic disorders and chemotherapy and radiation therapy. Finally, we will show how DTI can be used to predict height gain and final height compared to conventional bone age-based methods and standard growth charts, which are inaccurate and not generalizable to the current child/adolescent population. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Santos Laura, Jaramillo Diego, Raya José, Jambawalikar Sachin, Nguyen Jie, Mostoufi-moab Sogol

Keywords: magnetic resonance imaging, growth plate, diffusion tensor imaging

To compare how 3D MRI measurements of physeal cartilage volume, and DTI measurements (tract volume and length) correlate with growth parameters and detect differences in growth between patients treated with cis-retinoic acid and controls. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Duong Phuong, Mostoufi-moab Sogol, Raya José, Jaimes Camilo, Delgado Jorge, Jaramillo Diego

Keywords: magnetic resonance imaging, growth plate, short stature

There is growing research in diffusion tensor imaging (DTI) for providing metrics and images of physeal structure and function, particularly in evaluating children with possible growth disorders. There is a need for a faster automated process to segment the diffusion data, however. We utilized a deep learning algorithm to automatically generate a region of interest (ROI) for use in fully automatic diffusion tensor tractography of cartilage columns in the distal femoral physis. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Mutasa Simukayi, Liu Michael, Duong Phuong, Jambawalikar Sachin, Mostoufi-moab Sogol, Jaramillo Diego

Keywords: Deep learning, growth disorders, MRi