Common normal variants of pediatric vertebral development that mimic fractures: a pictorial review from a national longitudinal bone health study
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Children with glucocorticoid-treated illnesses are at risk for osteoporotic vertebral fractures, and growing awareness of this has led to increased monitoring for these fractures. However scant literature describes developmental changes in vertebral morphology that can mimic fractures. The goal of this paper is to aid in distinguishing between normal variants and fractures. We illustrate differences using lateral spine radiographs obtained annually from children recruited to the Canada-wide STeroid-Associated Osteoporosis in the Pediatric Population (STOPP) observational study, in which 400 children with glucocorticoid-treated leukemia, rheumatic disorders, and nephrotic syndrome were enrolled near glucocorticoid initiation and followed prospectively for 6 years. Normal variants mimicking fractures exist in all regions of the spine and fall into two groups. The first group comprises variants mimicking pathological vertebral height loss, including not-yet-ossified vertebral apophyses superiorly and inferiorly, which can lead to a vertebral shape easily over-interpreted as anterior wedge fracture, physiological beaking, or spondylolisthesis associated with shortened posterior vertebral height. The second group includes variants mimicking other radiologic signs of fractures: anterior vertebral artery groove resembling an anterior buckle fracture, Cupid’s bow balloon disk morphology, Schmorl nodes mimicking concave endplate fractures, and parallax artifact resembling endplate interruption or biconcavity. If an unexpected vertebral body contour is detected, careful attention to its location, detailed morphology, and (if available) serial changes over time may clarify whether it is a fracture requiring change in management or simply a normal variant. Awareness of the variants described in this paper can improve accuracy in the diagnosis of pediatric vertebral fractures.
KeywordsOsteoporosis Normal variants Spine Fracture Radiography Child
This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work has been provided to Dr. Leanne Ward by the Canadian Institutes for Health Research New Investigator Program, the Canadian Child Health Clinician Scientist Career Enhancement Program, a University of Ottawa Research Chair Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the Children’s Hospital of Eastern Ontario Research Institute and the University of Alberta Women and Children’s Health Research Institute.
The Canadian STOPP Consortium would like to thank the following individuals:
The children and their families who participated in the study and without whom the STOPP study would not have been possible;
Research associates who managed the study at the co-ordinating center (the Children’s Hospital of Eastern Ontario, Ottawa, Ontario): Elizabeth Sykes (STOPP Project Manager), Maya Scharke (STOPP Data Analyst and Database Manager), Monica Tomiak (Statistical Analyses), Victor Konji (STOPP Publications and Presentations Committee Liaison), Steve Anderson (Children’s Hospital of Eastern Ontario Pediatric Bone Health Program Research Manager), Catherine Riddell (STOPP National Study Monitor);
Research associates who took care of the patients from the following institutions: Alberta Children’s Hospital, Calgary, Alberta: Eileen Pyra; British Columbia Children’s Hospital, Vancouver, British Columbia: Terry Viczko, Sandy Hwang, Angelyne Sarmiento; Children’s Hospital of Eastern Ontario, Ottawa, Ontario: Heather Cosgrove, Josie MacLennan, Catherine Riddell; Children’s Hospital, London Health Sciences Centre, London, Ontario: Vinolia ArthurHayward, Leila MacBean, Mala Ramu; McMaster Children’s Hospital, Hamilton, Ontario: Susan Docherty-Skippen; IWK Health Center, Halifax, Nova Scotia: Cindy Campbell, Aleasha Warner; Montréal Children’s Hospital, Montréal, Québec: Valérie Gagné, Diane Laforte, Maritza Laprise, Ste. Justine Hospital, Montréal, Québec: Claude Belleville, Natacha Gaulin Marion; Stollery Children’s Hospital, Edmonton, Alberta: Ronda Blasco, Germaine McInnes, Amanda Mullins; Toronto Hospital for Sick Children, Toronto, Ontario: Alexandra Airhart, Michele Petrovic, Nicole Sarvaria; Winnipeg Children’s Hospital, Winnipeg, Manitoba: Dan Catte, Erika Bloomfield, Jeannine Schellenberg; as well as the research nurses, support staff and all the STOPP collaborators from the various divisions of Nephrology, Oncology, Rheumatology and Radiology who have contributed to the care of the children enrolled in the study.
Conflicts of interest
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