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Growth arrest lines and physeal stress injury

Case contributed by Dalia Ibrahim
Diagnosis possible

Presentation

Bilateral knee pain.

Patient Data

Age: 16 years
Gender: Female

Right knee

mri

Delayed closure of the physeal plates of the examined bones, with widening and irregularities of the physeal plates (evident at the femoral physeal plates) and multifocal physeal cartilage ingrowth into the metaphysis with asymmetric edema of the metaphysis.

Multiple hypointense transverse sclerotic lines are seen in the metaphysis of the examined bones, evident on T1 WI.

Delayed closure of the physeal plates of the examined bones, with widening and irregularities of the physeal plates (evident at the femoral physeal plates) and multifocal physeal cartilage ingrowth into the metaphysis with asymmetric edema of the metaphysis.

Multiple hypointense transverse sclerotic lines are seen in the metaphysis of the examined bones, evident on T1 WI.

Multiple transverse sclerotic metaphyseal lines, representing growth arrest lines.

The first image shows widening and irregularity of the physeal plates (red arrow) with cartilage ingrowth in the metaphysis (yellow arrow) and asymmteric metaphyseal marrow edema (blue arrow)

The second image shows multiple metaphyseal transverse sclerotic lines eliciting low signal on T1 WI and and appears sclerotic on X ray.

Case Discussion

The case shows multiple osseous features secondary to prolonged exposure to physical stress in the form of:

  • delayed closure, widening, and irregularities of the physeal plates, with physeal plate cartilage ingrowth into the metaphysis and asymmetric metaphyseal marrow edema.
  • growth arrest lines which appear as multiple metaphyseal transverse sclerotic lines

Metaphyseal growth arrest lines are seen in children who experience significant physical stress over a sufficient period such as infection or malnutrition, hypothyroidism,hyperparathyroidism, Cushing’s syndrome,juvenile chronic arthritis, and during chemotherapy for malignancies in childhood, or immobilization of extremities during orthopedic procedures. The radiographic finding of growth arrest lines occurs from alternating cycles of osseous growth arrest and growth resumption. This appears to result from pathologic levels of stress during bone development (e.g. disease, malnutrition).1

Stress on developing physal plates results in the following: The normal MR appearance of the physis is trilaminate with a hyperintense cartilaginous layer, a hypointense zone of provisional calcification, and a hyperintense area of metaphyseal vascularization. During physeal stress injury, there's an abnormal widening of the hyperintense cartilaginous layer secondary to abnormal mineralization. This might be diffuse or focal giving an irregular appearance, and also when focal, discrete foci of increased T2 signal may be seen, representing ingrowth of cartilage into the metaphysis due to failed ossification of physeal cartilage.2

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