Inherited bone dysplasias

The diagnosis of child abuse is sometimes entertained at the initial presentation of infants with inherited bone dysplasias, which are extensively catalogued in the On Line Mendelian Inheritance in Man (OMIM®) with unique phenotype MIM numbers (1, 2). The conditions which can potentially lead to the mistaken diagnosis of child abuse are those with metaphyseal irregularity and fragmentation. Langer and colleagues described a form of spondylometaphyseal dysplasia (SMD) with metaphyseal fragmentation similar to that noted with abuse, and termed this condition SMD, Sutcliffe/corner fracture type (MIM 184255) (3–5). Patients with this disorder are short, with progressive coxa vara. The condition is genetically transmitted, with either autosomal or X-linked dominant inheritance. Although the radiographic features are strikingly similar to those in child abuse, the long bones are short and dysplastic and the spine is abnormal (Fig. 7.1). With weight-bearing, remodeling, and evolution of the dysplastic features, conspicuous medial metaphyseal fragments may be associated with tibia vara (Fig. 7.2).

Figure 7.1 SMD, corner fracture type. A, AP view of a one-year-old child with short stature reveals metaphyseal irregularity of the proximal left tibia with an osseous fragment medially, suggesting a corner fracture (curved arrow). Metaphyseal irregularity is noted involving the distal femur, most evident medially (straight arrow). B, AP view of the left humerus demonstrates metaphyseal irregularity proximally and to a lesser extent distally. The humeral shaft is shortened. C, Lateral view of the upper lumbar spine shows a biconvex appearance to the vertebral bodies (arrows). D, AP view of the right knee at 14 months of age shows little change in the appearance of the metaphyseal fragments. True metaphyseal lesions associated with abuse are excluded owing to the lack of significant interval change. Widespread dysplastic changes were noted elsewhere.

Figure 7.2 SMD, corner fracture type. A two-year-old child with short stature and focal dorso-lumbar kyphosis. A, AP standing view of the tibias shows bilateral tibia vara with a downward slope of the proximal tibial physes. There is sclerosis of the metaphyses with conspicuous osseous fragments resembling corner fractures (arrows). Lesser changes are evident in the distal tibias. B, Lateral view of the thoracolumbar spine demonstrates an acutely angulated kyphosis with hypoplastic and posteriorly situated T12 and L1 vertebral bodies (arrows).

The metaphyseal dysplasias (MD) are a heterogeneous group of skeletal disorders, and like SMD, they generally pose no diagnostic confusion with abuse (4, 5). An exception is MD, Schmid type (MIM 156500), an autosomal dominant chondrodysplasia due to a variety of mutations in the COL10A1 gene. Kleinman reported an infant with normal stature and metaphyseal changes that were initially suspected to be due to abuse (6). Skeletal survey (SS), clinical, and radiographic follow-up, and the presence of similar findings in the father and a subsequent sibling confirmed this autosomal dominant condition (Fig. 7.3). In earlier discussions, attention has been drawn to the metaphyseal and physeal changes of the proximal femurs with inflicted injury (see Chapter 3), and birth trauma will be discussed subsequently (see Chapter 11). Quite similar findings may be encountered in MD, Schmid type as well as SMD, Sutcliffe/corner fracture type, with discrete osseous fragments arising from the medial femoral and tibial metaphyses with progressive coxa vara (Fig. 7.4) (7). The other radiologic and clinical findings readily permit differentiation from traumatic injury. A missense mutation of the COL10A1 gene has also been shown to cause the rare Japanese variety of SMD. Savarirayan noted that 9.1% of cases of MD, Schmid type have mild spinal changes. Since both the MD, Schmid type and the Japanese form of SMD have similar collagen X abnormalities, the conditions are likely one and the same (MIM 156500) (1, 8).

Figure 7.3 Metaphyseal dysplasia, Schmid type. A, AP view of the lower extremities in a five-month-old child with clinical suspicion of leg length discrepancy demonstrates metaphyseal irregularities (straight arrows) of the distal femurs and proximal right tibia, suggesting corner fractures. Sclerosis and irregularity is noted in the left distal tibial metaphysis (curved arrow). B, AP view of the right proximal humerus shows an irregular bony spur arising from the medial humeral metaphysis (curved arrow). The distance between the ossified epiphysis and metaphysis is increased. Irregularity and sclerosis of the distal humerus and acromion process (straight arrow) are evident. Height at this time was greater than the 95th percentile and weight was at the 50% percentile. The patient developed coxa vara and increased femoral bowing requiring osteotomy. C, AP view of the left knee at age two years demonstrates persistent irregularity and sclerosis of the distal femoral metaphysis. The diagnosis was subsequently made in the father and a younger sibling. (From Kleinman PK. Schmid-like metaphyseal chondrodysplasia simulating child abuse. AJR. 1991;156:576–8.)

Figure 7.4 Metaphyseal dysplasia, Schmid type. A 20-month-old child with progressive bowing of the lower extremities. A, AP standing view of the lower extremities shows metaphyseal irregularity and sclerosis, most evident in the medial aspects of the proximal tibias (arrows). B, AP view of the pelvis demonstrates coxa vara with conspicuous medial metaphyseal fragments (arrows) simulating corner fractures.

Other SMD and MD forms have variable and sometimes dramatic metaphyseal irregularities/fragmentation, and these are usually associated with other distinctive radiologic, clinical, and/or laboratory findings. One such example is cartilage hair hypoplasia (CHH), also known as MD, McKusick type (MIM 250250) – the metaphyseal irregularities may be accompanied by flaring of the costochondral junctions (CCJs) (Fig. 7.5) (4, 5). In contrast to fractures of the CCJs, the rib ends are diffusely expanded and irregular.

Figure 7.5 CHH. A two-year-old child with short stature. Genetic testing revealed compound heterozygous RMRP mutation consistent with CHH. A, AP view of the lower extremities shows short tibias with metaphyseal flaring, sclerosis, and irregularity. B, Frontal view of the chest shows diffusely expanded and irregular CCJs (arrows).

Osteopetrosis

Osteopetrosis refers to a variety of rare genetic disorders characterized by increased bone density (MIM 259700, 259710, 611490). Although it does not pose differential difficulties with child abuse, there are several aspects of the condition that are relevant to this discussion (4, 5). The classic severe autosomal recessive form is characterized by short stature, bone marrow failure, fractures, and compressive neuropathies. Diagnosis is readily apparent on radiographs based on dense bones, metaphyseal lucencies/irregularities, and a “bone-in bone” ossification pattern, which may persist long after the normal “bone-in-bone” pattern of young infancy resolves (Fig. 7.6).

Figure 7.6 Osteopetrosis. A two-month-old infant with osteopetrosis and hypocalcemic seizures. A, AP radiograph of the chest shows diffuse increased bone density. An oblique lucency extends across the right acromion process (thick white arrow), consistent with a slightly displaced fracture. Lucent metaphyseal bands are evident in the humeri (thin arrows) with similar changes in the tips of the acromion processes (arrowheads). There is a bone-in-bone appearance of the posteromedial ribs, simulating healing rib fractures (thick black arrows). B, Two weeks later an AP view of the pelvis shows bilateral oblique lucencies extending through the SPR, suggesting fractures (arrows). Metaphyseal lucencies and irregularity are evident in the proximal femurs. C, Four weeks later, there is little change in the SPR lucencies, suggesting normal variants. Note that a bone-in-bone appearance in the iliac wings has become more accentuated (arrows).

Hypocalcemia may result in tetanic seizures, and these myoclonic/tonic episodes appear to be responsible for the rarely described acromial fractures in young infants with osteopetrosis (Fig. 7.6) (9). Acromial fractures in otherwise normal infants are highly associated with abuse (see Chapter 5), and the occurrence of these fractures in osteopetrosis, as well as neonatal tetanus (see Fig. 5.64) and other seizure disorders, suggests that abnormal tractional forces on the acromion are responsible for these distinctive injuries (10, 11). It is not unusual to encounter nonspecific long bone fractures with osteopetrosis, and there should be no confusion with inflicted injury (12, 13). The case of osteopetrosis in Fig. 7.6 also showed bilateral oblique lucencies extending through the superior pubic rami (SPR). Whether these represent fractures (see Chapter 3) or normal developmental variants (see Chapter 12) is unclear, but their persistence on follow-up suggests variants, perhaps related to the underlying disordered ossification. Figure 7.6 also illustrates lucent metaphyseal bands and a bone-in-bone appearance of the posteromedial ribs, which can simulate healing fractures.

Rachitic changes may be encountered in osteopetrosis, and these radiographic features, in conjunction with those related to vitamin D and calcium administration may result in unusual ossification patterns, apparent metaphyseal fragmentation, and SPNBF that suggest traumatic injury (Fig. 7.7) (14, 15).

Figure 7.7 Osteopetrosis. A five-month-old infant with osteopetrosis on calcium supplementation, awaiting bone marrow transplantation. AP views of the left humerus (A) and forearm (B) show conspicuous SPNBF (arrows) along the humeral and radial shafts. There is an evolving bone-within-bone appearance with amorphous ossification in the metaphyses. The SPNBF extends to the overlapping margins of the distal humeral and proximal radial metaphyses, giving the impression of displaced fractures.

Multiple hereditary exostoses

Multiple hereditary exostoses (MHE) (MIM 133700) is an autosomal dominant condition which is usually diagnosed in children based on exophytic osseous masses, often associated with a family history of the disorder (4, 5). When the rib lesions are encountered on a chest radiograph, the findings may be misinterpreted as multiple healing rib fractures and concerns of abuse can result (Fig. 7.8). Rib radiographs with attention to bone detail, and SS are diagnostic.

Figure 7.8 MHE masquerading as healing rib fractures. A four-month-old infant with respiratory distress. A, Frontal radiograph of the chest done elsewhere shows multiple foci of ossification (arrows) interpreted as healing anterior rib fractures resulting in transfer for suspected abuse. B, AP view of the thorax, optimized for bone detail, shows multiple exostoses (arrows). The diagnosis of MHE was confirmed with the demonstration of additional osteochondromas in the extremities (not shown).

Hereditary sensory and autonomic neuropathies

The hereditary sensory and autonomic neuropathies (HSAN) are a rare group of disorders associated with sensory dysfunction (16). There has been considerable research that provides a genetic classification of these complex and varied conditions, but much phenotypic variation occurs. Historically the diagnosis has been based on clinical evaluation combined with sensory and autonomic assessments, but genetic testing is now customary.

Congenital insensitivity to pain

Congenital insensitivity (indifference) to pain is a rare syndrome inherited as an autosomal recessive trait. It can be associated with lesions that mimic inflicted skeletal injury (17, 18). Affected children have normal intelligence and their neurologic examination results are normal except for insensitivity or indifference to painful stimuli. Light and deep touch and proprioception sensations are normal, although temperature perception is diminished in a few affected patients. Sweating is usually absent (anhidrosis). Because of the lack of pain, both minor and major trauma to the growing skeleton may go undetected until marked deformity is present. Repeated unrecognized injuries to the physis lead to epiphyseal separations and nonunion. In a child without symptoms or history of trauma, the presence of osseous injury may raise concerns of child abuse (16, 19). Images of an affected area may show fractures and epiphyseal separations in various stages of repair. In addition to shaft fractures, metaphyseal injuries are common during early childhood (20). Metaphyseal chronic osteomyelitis is also an occurrence during childhood, perhaps because of the increased incidence of skin infections secondary to the multiple burns and lacerations incurred by affected children. Imaging features of osteonecrosis/osteochondritis dissecans are common in weight-bearing joints (Fig. 7.9) (21). By adolescence, repetitive microtrauma to the pain-insensitive joint can result in neuropathic arthropathy.

Figure 7.9 Congenital indifference to pain. AP radiograph of the knee in a nine-year-old boy shows physeal widening and metaphyseal irregularity of the proximal tibia. Osteonecrosis is present in the lateral femoral condyle (arrow).

Riley–Day syndrome

Riley–Day syndrome, or familial dysautonomia, is a rare autosomal recessive neurodevelopmental disorder that affects the central nervous system (5). It is characterized by deficits in peripheral autonomic and sensory neurons. Skeletal complications included fracture, osteomyelitis, septic arthritis, and neuropathic arthropathy. Dramatic acral osteolysis may result from self-mutilating behavior, which can be complicated by soft tissue infection and osteomyelitis (Fig. 7.10).

Figure 7.10 Riley–Day syndrome with acral osteolysis and osteomyelitis. PA view of the left hand of a two-year-old with Riley–Day syndrome shows variable amputation of the distal phalanges of the second to fourth fingers (arrows) due to self-mutilating behavior, complicated by cellulitis/osteomyelitis.

Myelodysplasia and other paralytic disorders

Myelodysplasia

Thoracic and lumbosacral spinal dysraphism with underlying spinal cord and nerve root abnormalities will result in variable degrees and levels of sensory loss and paralysis in the lower extremities. The lack of normal motor function results in decreased bone mineral density (BMD) and a greater tendency to fracture, particularly in wheelchair-bound children (22). With severe motor involvement, periarticular soft tissue contractures may develop in infancy, and diapering and other routine handling can result in shaft fractures. These injuries may be undetected unless gross hemorrhage and marked displacement are present or callus is eventually palpated (23, 24). In older children without total lower extremity paralysis, ambulation is often encouraged. Braces and crutches contribute to stresses to the physis and the metaphysis, resulting in Salter–Harris (SH) physeal fractures and epiphyseal separations. Repeated minor trauma leads to metaphyseal fragmentation, periosteal elevation, and hemorrhage into the physis (25). The metaphyses become dense and irregular, the physis appears wide, and SPNBF/heterotopic bone become visible during healing (Fig. 7.11).

Figure 7.11 Myelodysplasia. AP (A) and lateral (B) views of the right knee in a four-year-old child with spina bifida reveal fragmentation, sclerosis, and irregularity of the metaphyseal–epiphyseal regions. The physes are widened and extensive SPNBF is present involving the femur and tibia.

These neuropathic changes are the Charcot joint equivalent in the growing skeleton. Similar, but less dramatic physeal injuries occur in myelodysplastic infants and children undergoing vigorous physical therapy for contractures. Occasionally, fractures occur with appearances that suggest the classic metaphyseal lesion (CML) noted with abuse (Fig. 7.12). Careful inspection usually reveals the fractures to be epiphyseal separations of the SH type II variety. Fractures occur below the level of neurologic involvement, affecting predominantly the femur in patients with thoracic involvement and the tibia in those with lumbar involvement. Fractures are more frequent in cases with thoracic spine defects (26). Physeal widening resolves quickly with the use of orthoses and limitation of activity. Early physeal closure and growth disturbance may be prevented by such therapy (27). Although progression to Charcot’s arthropathy is a potential complication, complete healing is possible. Since these bone changes occur in the lower extremities in children with known spinal dysraphism, and the typical underlying osseous changes of the condition are evident, differentiation from child abuse is usually simple. However, confusion with inflicted injury has been reported (28).

Figure 7.12 Myelodysplasia. AP (A) and oblique (B) views of the distal right tibia in an 18-month-old boy with myelodysplasia demonstrate a metaphyseal fracture. On the oblique view (B) the injury has a corner fracture appearance (large arrow). On the frontal projection (A) the osseous density (small arrows) is noted to be separated from the metaphysis, suggesting that this is a SH type II physeal injury. The child had recently undergone vigorous physical therapy for the lower extremities. (Courtesy of David G. Dissler MD.)

Cerebral palsy

Other paralytic neurologic disorders may result in osteopenia and gracile bones, predisposing to fracture. Children with cerebral palsy are at risk for fracture with routine handling and aided ambulation (29–31). Less commonly they may sustain SH physeal injuries that can be delayed in presentation (Fig. 7.13). Fractures may also occur during spastic muscle activity and children with epilepsy are at increased risk of such injuries (32). Ballal and others described a proximal femoral epiphyseal separation following seizures in 22-month-old and 9-year-old children with cerebral palsy (33). An additional case of a 5-month-old infant with a proximal femoral physeal injury following a grand mal seizure was described by Aoudi and others (34). As noted, patients with paralytic disorders are at risk for fracture when undergoing physical therapy or other strenuous manipulation of an involved extremity.

Figure 7.13 Severe spastic cerebral palsy. A, AP view of the left humerus in a 13-year-old boy with severe spastic cerebral palsy and left shoulder swelling demonstrates a proximal epiphyseal separation. The epiphysis is displaced and there is exuberant callus and SPNBF. B, During restraint in the Radiology Department for a subsequent radiograph of the humerus, the child evidenced sudden spastic contraction of the left upper extremity, and an audible snap was appreciated. This subsequent view of the humerus revealed a new angulated fracture of the humerus.

Grayev and others described tibial injuries in 8 children, 1–4 months old, who underwent serial casting for clubfoot (35). Two patients had myelodysplasia and one had arthrogryposis. All children manifested injury with periosteal new bone formation. One child with bilateral tibial metaphyseal fractures had clear evidence of abuse with 24 rib fractures. Four other children had metaphyseal fractures resembling CMLs, and three developed an area of sclerosis within the metaphysis. The authors stressed the need to consider an iatrogenic basis for metaphyseal injuries in children undergoing orthopedic treatment and casting for congenital foot/ankle deformities. They suggested that the mechanics entailed in these orthopedic manipulations provides insights into the mechanisms of similar metaphyseal injuries occurring in the setting of abuse. Kleinman described a metaphyseal fracture in a four-month-old child with arthrogryposis who was found to have distal tibial and fibular metaphyseal fractures following manipulation for clubfoot deformity (Fig. 7.14) (36). It was unclear if the fracture occurred as a result of the orthopedic manipulation or during the dorsiflexion positioning routinely performed during radiographic assessment. It should be kept in mind that children with disabilities may be at increased risk of abuse (see Chapter 23).

Figure 7.14 Iatrogenic metaphyseal fracture. A, Lateral view of the left ankle and foot of a four-month-old child with arthrogryposis and left clubfoot shows equinus deformity. B, Lateral view of the same foot obtained shortly after manipulation shows metaphyseal fractures of the distal tibia (thick arrow) and fibula (thin arrows). (Published with permission from Kleinman PK. Problems in the diagnosis of metaphyseal fractures. Pediatr Radiol. 2008;38(Suppl. 3):S388–94.)

Infection

Osteomyelitis and septic arthritis

Young infants with osteomyelitis and/or septic arthritis often present with irritability and reluctance to use the extremity. The shoulder and hip are common locations. Initial radiographs may be normal or misleading. Since fever may be absent, a traumatic injury may be the initial consideration. Osteomyelitis and septic arthritis of the shoulder can be particularly problematic because SPNBF may be construed as traumatic, and an apparently abnormal glenohumeral relationship suggests dislocation or a displaced SH injury (Fig. 7.15). Sonography is useful to document a normal physis and glenohumeral relationship, and can also demonstrate medullary metaphyseal destruction (osteomyelitis) with epiphyseal involvement (chondritis). Magnetic resonance imaging (MRI) elucidates the inflammatory findings.

Figure 7.15 Osteomyelitis and septic arthritis. An 11-day-old infant with 1-day history of right shoulder swelling and not moving arm. Radiographs elsewhere suggested a traumatic dislocation and the infant was transferred with concerns of abuse. There was no fever. A, AP view of the right shoulder shows apparent widening of the glenohumeral articulation (black arrow). SPNBF is evident along the proximal humerus and the distal clavicle (white arrows). There is subtle permeative destruction of the humeral metaphysis (*). B, Coronal sonograms of the right and normal left shoulders demonstrate loss of the normal echogenic band of the ZPC (thick straight arrows) as well as abnormal epiphyseal cartilage echotexture (thin arrows) on the right. Note focal cortical destruction (curved arrow). C, Coronal T1W FS gadolinium-enhanced MRI shows diffuse intense synovial enhancement (thin arrows) and a joint effusion (e). Note the focal juxtaphyseal enhancement (thick arrows) and cartilage enhancement defect (*) within the epiphysis consistent with metaphyseal osteomyelitis extending to the nonossified epiphysis (chondritis). Culture of the purulent material at arthrotomy grew group B streptococcus.

A pathologic fracture through a focus of osteomyelitis may be confused with an inflicted injury involving the metaphyseal epiphyseal complex (Fig. 7.16) (37). Since the process commonly involves the epiphyseal blood vessels in infants, osteomyelitis can result in a growth disturbance and long-term orthopedic deformity (Fig. 7.17) that may be indistinguishable from a traumatic physeal injury without associated infection (see Fig. 3.14).

Figure 7.16 Osteomyelitis with pathologic fracture. A seven-month-old infant not moving left arm. There was no fever or history of trauma. A healing humeral fracture was noted radiographically and concerns of abuse were raised. A, AP view of the left humerus shows a transverse metaphyseal fracture (long arrow) through a region of permeative bone destruction. There is SPNBF and soft tissue swelling (short arrows). B, Coronal T1W MRI shows a displaced metaphyseal fracture (long white arrow).There is abnormal low marrow signal at the level of the fracture and at two other sites in the shaft (short arrows) consistent with abscesses. Note the SPNBF (black arrow). (With permission from Taylor MN, Chaudhuri R, Davis J, Novelli V, Jaswon MS. Childhood osteomyelitis presenting as a pathological fracture. Clin Radiol. 2008;63:348–51.)

Figure 7.17 Osteomyelitis with septic arthritis. A, A three-week-old previously healthy infant presented with the acute onset of swelling of the shoulder. The joint capsule is distended, causing lateral displacement of the humeral head (arrow). In addition, there is lateral displacement of the shaft from the head as a result of a fracture through the physis. B, Four days later, after aspiration of the joint, the shaft is no longer displaced. The ossification center of the humeral head is no longer visible, because of either destruction by lytic pus or demineralization secondary to hyperemia. Lytic areas are present in the metaphysis (arrow). SPNBF cloaks the proximal shaft and is also present along the axillary border of the scapula. The metaphyseal destructive lesions distinguish osteomyelitis from child abuse. C, Changes of healing are evident one month later during treatment with IV antibiotics. Exuberant dense SPNBF (involucrum) surrounds the proximal and midhumeral shaft. The SPNBF along the scapula has become better defined as healing progresses. D, Six months later, there is complete healing of the infection with severe residual deformity. The humeral head is not well defined and the shaft is inferiorly and medially displaced. The metaphysis is wide, with a forked surface.

When osteomyelitis and septic arthritis of the hip are present in infants, the pathologic fracture can occur thorough the physis resulting in an epiphyseal separation that can also be confused with a purely traumatic injury. In neonates and young infants with a nonossified proximal femoral epiphysis, displacement of the metaphysis may also be mistaken for a hip dislocation (38, 39). Sonography provides a simple means of documenting that the separated femoral epiphysis is normally situated in the acetabulum. A similar epiphyseal separation has also been noted in the distal femur of a 45-day-old infant (38).

Ribe and Changsri described a unique case of a pathologic fracture through a focus of osteomyelitis in a fatally abused child (Fig. 7.18) (40). Radiographically, the process was accompanied by expansion of the medullary cavity with a sclerotic rim, and at autopsy, a medullary abscess with surrounding scar tissue was present, all features indicating chronicity.

Figure 7.18 Osteomyelitis in an abused infant. A 4-month-old former 31-week premature infant was found dead in bed. Autopsy showed acute bronchopneumonia, three partially healed skull fractures, a chronic SDH, chronic intracerebral hemorrhage, RHs, multiple healing rib fractures, a fractured fibula, and a partially healed fracture of the distal right radius. The fracture of the right radius showed a medullary abscess containing pus and granulation tissue surrounded by scar tissue. (Reprinted with permission from Ribe JK, Changsri C. A case of traumatic osteomyelitis in a victim of child abuse. Am J Forensic Med Pathol. 2008;29:164–6.)

Deficiency of interleukin-1-receptor antagonist syndrome is a rare auto-inflammatory condition that can produce diffuse SPNBF and focal areas of bone destruction. The other manifestation of this life-threatening autosomal-recessive condition should prevent any confusion with inflicted skeletal injury (41).

Meningococcemia

In infantile meningococcemia with septic emboli to epiphyseal vessels, ischemia may damage the physis, causing physeal growth disturbance with resultant limb shortening and angular deformity (Fig. 7.19) (42–44). Central physeal fusion may lead to cone-shaped epiphyses and metaphyseal cupping. Vascular occlusion and osteomyelitis may cause autoamputation of multiple digits in the hands or feet. Differentiation from abuse is made on the basis of the history of fulminant sepsis in early childhood.

Figure 7.19 Meningococcemia with osteomyelitis, the long-term consequences. A six-year-old child with a history of meningococcemia in infancy. A, B, Frontal and lateral views of the left knee show mixed sclerosis and lucency in the distal femoral epiphysis and the proximal tibial metaphysis. There is lateral and posterior subluxation of the knee and anteromedial angular deformity of the proximal tibia related to a physeal growth disturbance. C, PA view of the hands demonstrates widespread digital amputations related to septic emboli and ischemia. (A, B, Published with permission from Kleinman PK. A regional approach to osteomyelitis of the lower extremities in children. Radiol Clin North Am. 2002;40:1033–59.)

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