X-ray results

Is it possible for a new injury to show up on an xray looking like an old injury?

The doctors say it looks old and it must be from years ago but my daughter has never had any problems with her fibula before. (Although she did have a spiral fracture in her tibia twice)

She has had over 30 xrays in the last 18 monhts and there is nothing wrong with the fibula in any of them? Now the xray shows a salter harris fracture of fibula and malleolus.

Does it seem reasonable and likely that this did not show up on over 30 xrays??

Is there anything which will present as an old injury when it is actually a new one?
Thanks to anyone who can help!

[Caliber2005]

Hi Moon,
As I have mentioned in earlier post that it is difficult to find an injury which is recent one and it looks like it is old one.
Calcification around the site of injury says whether it is old or new injury.
Her history is suggestive of something going wrong with her ankle joint, but since it was manageable, hence no x-rays were taken or even if they were taken, the injury was not clear. After these 2 injuries i.e. spiral fracture of her tibia and malleolus, there would have been growth and healing happening at the site.
This healing is not what is apparent on x-ray. (Fracture of indeterminate age).
Have they diagnosed any type of fracture in Salter-Harris classification? If yes, which type of Salter-Harris fracture they have diagnosed?
What has the doctor explained you regarding the fracture?
What are his modalities of management now?
Is she on Calcium and Vitamin supplements?
Keep me informed about her health.
Bye.

[blayzmoon]

Thank you so much for your detailed replies. Thay were quite helpful. The doctors did say there were different types of SH fracture but did not tell me which they had classified hers as. It is also not noted in her records which type it is. All it says is Salter Harris. They have explained nothing regarding her SH fracture. They basically ignore that, even though that is what caused me to go to them in the first place. She gets checks on her old spiral tibia injury every 6 months, the last was on Sep 30th this year, when i was told her tibia was fine. They keep telling me her current issues are what is important not the SH. As far as i was aware the SH is her current issue, thats why they casted it for 3 weeks. They are doing nothing right now. Yesterday they took a standing xray (they have not done this before), and said they will do noting until she goes in in 6 months time so they can do a comparison standing xray. They say they need a comparison to find out what exactly is going on and at what pace. I give her daily multivitamin tablets for kids, but her doctor told me it was not needed. I have never heard of bi-phosphonates.

[Caliber2005]

Hi,
I am feeling nice that my post was of some help to you.
Regarding the Salter-Harris type of classification of fracture, usually there are five distinct types. All these fractures are related to growth plates and are classified according to the damage which has occurred.
The Salter-Harris classification is universally used.
5 patterns of growth plate fractures are noted (types III, IV, and V are at high risk for growth plate damage)
Type I: Split along and parallel to the growth plate without involvement of the metaphysis or epiphysis.
Type II (most common): Split along the growth plate that exits through the metaphysis.
Type III: Intra-articular fracture of the epiphysis that exits transversely out of the growth plate.
Type IV: Fracture of the epiphysis that exits through the metaphysis
Type V: Crush injury to the growth plate.
This is done usually to prognosticate about the recovery of injury.
What treatment modalities the doctor's have planned for your child?

[blayzmoon]

So far they have no treatment plans at all for her. They told me yesterday to make a 6 month follow up appointment,and that they would do nothing until she comes back in 6 months for the new standing xrays. They told me she could use an ankle brace if i felt the need for it but that they would advise against it as it will help keep the ankle from rolling but may damage the other areas of the leg / ankle by weakening them. He told me yesterday that there is nothing they can do until they see any idfferences in her xrays taken yesterday and the next ones which will be taken in June 2008. Until then, they are doing nothing at all. Even then they did not say what might happen in June 2008. Would there be a reason they would not have made an entry in her notes stating which kind of SH it was? Thanks again!

[Caliber2005]

Hi,
Treatment modalities I meant were planning a multi-disciplinary approach for your child until next 6 months.
Regarding her imaging I thought MRI would have been better. MRI is the best method with which to diagnose an established injury to the growth plate. It shows the cartilage line of the growth plate as distinct from bone. Order a gradient echo sequences of the growth plate to know actual the type of damage to the growth plate. (This should be discussed with the radiologist in advance to select the best settings.)
Non-weight bearing is indicated for lower extremity fractures, and complete rest is given to the part.
Pain control is indicated.
Prognosis and complications varies depending on severity of injury.
I am not sure of whether they have made entry of what kind of SH it is or why they have not made.
What prognosis and complications they have explained to you? What monitoring they would be doing for your daughter apart from limb inequality?

[blayzmoon]

Hi again,
I will ask about getting her an MRI.They said she should carry on as normal until her next appointment, and had her hopping on her leg with the problems and jumping and running in the hallway of the ortho clinic. They said not to stop her from doing anything she would normally do. They have explained nothing to me, about the prognosis or complications. All they said was it was growing asymmetrically. I asked what we should do about that and the doctor said there is nothing to do right now, bring her ack in 6 months time and i will xray it again to see what has changed. They do not intend any type of monitoring for her in the next 6 months. The only other monitoring she gets is the regular 6 month checks on her tibia to make sure it is growing paralell to the growth plate. The next routine check for this is in March. To recap, they said not to restrict her at all. Her next check for her tibia growing paralell to the growth plate is in March. The next check for her limb inequality is in June. Unfortunately my daughter sees a different doctor almost every time she goes as we live on a US army base, and people change all the time. Those who have seen her before are typical military - get you in get you out as fast as possible. The last two visits they thought they were checking her tibia and wrote such in  her notes and i had to point out to them they were meant to be checking on her fibula and malleolus, not her tibia. They have also accidentally xrayed the wrong leg once. Can you tell me what they should have told me with regards to prognosis and complications? What should they be doing for her? These people are used to dealing with grown-ups, soldiers. They are not used to dealing with a 6 year old girl, and are not good at it.  Thanks again!

[Caliber2005]

Hi blazymoon,
You have not shown your daughter to a Pediatric orthopaedician. I think you should take time off and make sure your daughter sees a Pediatric Orthopaedician. Your child is only 6 years old and has got whole life to live, if not taken care now; this might affect her whole life.
As of now I think pain medication can be used if compartment syndrome is not a concern.
As I told you earlier most growth plate fractures heal without difficulty. The higher the Salter-Harris classification, the more common is the incidence of growth abnormality.
If the patient is younger in skeletal maturity, the more would be growth abnormality. Anatomically, certain regions (e.g., distal tibia and distal femur) are more prone to growth disturbance and other regions (e.g., distal radius and proximal humerus) are relatively protected from growth disturbance.
Complications which can be noted are Growth arrest (growth plate stops growing) , Malunion, Growth disturbance (growth plate grows abnormally with resultant angulations), a more serious complication than growth acceleration.
Growth acceleration may occur which is due to increased blood flow for healing, which may occur in any child <10 years old with a fracture, and which usually amounts to only 5 to 10 mm.
Patient monitoring should be in place. Patients with growth-plate injuries are at increased risk of growth disturbance (Salter-Harris types III to V and all distal femur and distal tibial growth plate injuries) should be followed for at least 6 to 12 months to ensure normal growth.
At that time, the orthopaedician should:
Look for equality of limb length and angulations.
Look for the presence of a clean growth-plate line on a radiograph.
Look for the any growth-arrest lines of bone that was formed at the time of injury to be separated from the growth plate by an even layer of normal newly formed bone.
Which parts of US are you placed now?
I think you should take time off and show your child to a Pediatric Orthopaedician.
Alternatively, making her stand erect and you can check her height and individual limb lengths. What is her height now?
Bye.

[blayzmoon]

Hi,
Thanks again for all your helpful information. The specialist my daughter seen on Wednesday specialized in pediatrics and foot and ankle. He is the one i went to for a second opinion. He is the one who said he will do nothing until he has another xray to compare the differences in 6 months time. You mentioned something called growth arrest, i recalled reading that in her notes so i had a check back and it said 'Incidental note is again made of a growth arrest line over the distal tibial metaphysis.' This note is from one of her visits on 24 September. They said 'again noted' so i looked further back and on her visit dated 26 March it says 'Growth arrest lines incidentally noted of distal tibial metaphysis.' You mentioned growth arrest where the growth plate stops growing, but what do growth arrest lines mean? Also, upon reading over her notes i found another item which i did not understand and has never been explained to me, can you tell me what it means please? It says 'There is a small bony density noted next to the tip of the medial malleolus which could be due to a secondary ossification center' What is an ossification center? and is this of any importance? I am located in North Carolina. To note, my daughter does not often complain of any pain, except at her achilles tendon. My daughter is 48 inches/4 foot tall right now. She is 6 years and almost 3 months old. (D.O.B. 09/30/01) The xrays taken by the pediatric ortho showed that her knee on one leg is higher than the knee of the other leg. The pediatric ortho seemed more conerned with the asymmetrical growth and the possible twisting of her tibia growth due to the length of the original tibial spiral fracture. He did not appear to be overly concerned about her growth plates. Again, many many thanks for all your help and knowledge.

[Caliber2005]

Hi,
It is nice to see that you are concerned for your child and seeking information which can help her in any way.
What she meant by her finding is that there is an incidental finding on your daughters x-ray saying at the lower end of tibia there is a line of demarcation suggesting no further growth of bone in that part. There are two ossification center in long bones, primary ossification centre in diaphysis and secondary ossification centre in epiphyses.
The place where bone formation happens is called ossification center. It is important; as this is the place where from growth will be consistent.
I think your doctor is right for being concerned about asymmetrical growth as this can cause more deformity to child than any growth.
Keep me posted about her improvement in her ailment.
Tell my hi to her and lots of love.
What is her name?
Bye.

[Caliber2005]

Hi,
It is nice to see that you are concerned for your child and seeking information which can help her in any way.
What she meant by her finding is that there is an incidental finding on your daughters x-ray saying at the lower end of tibia there is a line of demarcation suggesting no further growth of bone in that part. There are two ossification center in long bones, primary ossification centre in diaphysis and secondary ossification centre in epiphyses.
The place where bone formation happens is called ossification center. It is important; as this is the place where from growth will be consistent.
I think your doctor is right for being concerned about asymmetrical growth as this can cause more deformity to child than any growth.
Keep me posted about her improvement in her ailment.
Tell my hi to her and lots of love.
What is her name?
Bye.

[blayzmoon]

Hi,
Her name is Blayz Moon, hence my name on here, and everywhere else i need a screen name. She is very intelligent, and wants to be a pediatritian specializing in orthopedics whe she is older. She has always wanted to be pediatritian, even when she was only 2 years old, but now she wants to have a specialty. She is top her class, even though she is a year younger than the other children. She is my only child and my whole world.
Thanks again for all your help and i'll keep you posted wth updates as we get them.

[Caliber2005]

Hi Blayz Moon,
What a lovely name.
I think it’s a nice idea that she wants to become a doctor and specialize in pediatrics and grow as Pediatric Orthopaedician.
May god make her wish come true.
I wish her all the best for all her future endeavors.
I think your doubt regarding ossification center is clear. I would be really worried if she has any asymmetrical growth.
We should ask for early intervention if we feel there is gross deformity in her leg and her gait while walking is compromised.
You should be aware of the need to bring the child for 6 to12-month follow-up of Salter-Harris classification III or IV fracture or any fracture of distal femur or proximal tibia.
Keep me posted regarding her health in general.
Also keep me informed regarding her orthopedic concerns.
I wish her the best in the world.
Bye.

[blayzmoon]

Hi, sorry to bother you again. I was curious as to where you got all your expertise from? Are you a doctor? or a physicians assistant? or do you get your excellent and very helpful information from somewhere else? Thanks again!

[JainMD]

Hi,
How are you? How is Blayz Moon?
I have changed my screen name. Yes, I am a doctor and for that matter a Pediatrician.
Why what is the concern and why are you worried all of a sudden?
How is your daughter, is she fine?

[blayzmoon]

Hi, sorry, no, nothing has changed with my daughter, she is fine. I was just speaking with my mother-in-law, and i was telling of all the findings with my daughter and i mentioned i had spoken to someone online about it all. She asked if the person i spoke with online was a doctor and i realised i had no idea if you were a doctor or not. I decided to ask, as you seemed very knowledgable, which is why it didn't occur to me to ask before. Blayz has a follow-up appointment to check on her fibula (only the fibula, she sees a different doctor for the assymetical growth etc.) on Jan. 11th. I would like to find a specific vitamin / mineral / herbal supplement for her to take - something which is specifically designed for bone and teeth strength. Do you know of such a supplement which is non-prescription? Although, when i take her on 11th i plan on asking about a prescription. I did have another question though. Can bone health and tooth health be linked? Her teeth have always been perfect, and at her latest cleaning / check-up the dentist said her teeth were still perfect, but then he gave her her first panoramic x-ray and discovered a tiny cavity in her first pre-molar, which only came through the gum in September. The dentist was shocked by this and said he would not have believed it possible with teeth like my daughters if he had not seen it on 2 different x-rays. Is it possible her cavity (which cannot be seen except on x-ray?) could be in any way linked to her bone strength etc. It seems unlikely to me that she could end up with a cavity when the tooth has only been in her mouth for a few months. I am obsessive about keeping her teeth healthy and clean. The shock from the dentist shows that. Could there be a link? or is that not possible? I did not mention any of the bone issues to her dentist mainly because i was in shock myself about the cavity. I should and would have asked him if i had been able to think clearly. Thanks again for your time and efforts. You are very helpful.

[JainMD]

Hi,
Yes, Dentists world wide think of decreased bone density whenever they find a cavity on oral examination. Dentists and dental hygienists aren't just looking for gum disease and cavities anymore. Bone health could be directly intertwined with the health of your jawbone, your teeth and even your gums.
Your answer regarding whether there is link between tooth having cavity and bone disease is yes there is a link.
In adults, if there is a cavity being found on dental x-ray, it suggests that the patient might have osteoporosis.
Similar profile if you extrapolate to kids health, suggests that they can have decreased bone density if they are found to have cavities in dental X-ray.
Have we done her Calcium, Vitamin D, Alkaline phosphatase and Vitamin D3 level for her?
I have asked to ask the orthopaedician regarding biphosphanates use in kids, this is the drug used to strengthen bone in kids.
Keep me informed about her disease progression.
Bye.

[JainMD]

Hi,
I would like to know where the cavity present on the tooth is.
Is it in the crown portion or the root portion of the tooth as the crown portion is visible to you and the root portion is inside the jaw bone?
It is possible to have a cavity which might not be seen with naked eyes, but found on an x-ray.
If the cavity is in the root portion, then it may be related to her bone health.
If it is in the crown portion, it may be between two teeth which might not be visible from naked eye.

[blayzmoon]

Hi,
The dentist could not see it at all with the naked eye, even when he looked at her teeth following the xray to see if her could find any sign of it. He said he would be filling it using the xray to guide him to where it showed up on the tooth, he would not be filling it using sight because he can't see it. He did not say where it was located though, and i did not think to ask because i was in shock.
Thanks for your help.

[JainMD]

Hi,
I think you should be asking the details when you visit him next. You can also quiz him regarding the connection with bone health and tooth health.
Bye.

[blayzmoon]

Hi again,
Nothing new going on, i just received the results from her last appointment with the pediatric orthopedician and it says in her notes he does not believe, from x-raying her legs that she ever had a spiral fracture in her tibia, rather, he believes it was a n oblique fracture. I have tried looking on the internet to find out the difference and how he could tell but have come up with nothing. Do you know the difference between spiral and oblique? and how he could tell? Thanks again!

[JainMD]

Hi,
The alignment of a spiral fracture and oblique fracture is same and hence line of management remains same.
I feel what he meant by difference in fracture is Oblique fracture is of definite length, but spiral fracture is not and it also covers the girth of bone.
May be this is how he would have explained it to you.
What he has to say about the pathology behind her cavity in tooth and her decreased bone density.
How is Blayz doing? How did she celebrate her new year?
Keep me informed.
Bye.

[blayzmoon]

Hello again,
Blayz had an appoinment today with her pediatric denitist to have her cavity filled and i asked him about there being a connection between her dental health and her history of fractures. He examined her and said the white of her eyes has a blue color to it, which indicates to him she may have a mild case of osteogenesis imperfecta +dental. She has an appointment on Friday with her ortho doctor and i will be asking for testing to get a definate diagnosis. Just thought we'd keep you up to date.
Thank again!

[treebranches]

I agree that she needs an MRI, hands down, and I just walked into this conversation.  I don't know what sort of history she has or how old she is, but I would try to get is taken care of as soon as possible since bodies heal better when younger; I myself could have been diagnosed with something when I was younger, but they never took an MRI (or even the correct x-rays) to see it -- that was a relatively new condition then, also.

Do you have other cases, that you know of, of osteogenesis imperfecta in your family?  I thought it was a genetic disease.

[JainMD]

Hi Blayz Moon,
What is your name Sir?
Osteogenesis Imperfecta is a collagen disorder causing osseous fragility. This disease may affect bones, teeth, eyes, hearing, and soft tissue.
Is her height less as compared to her age?
Does she have any hearing deafness?
Does her face appear to be triangular in shape, like widened cranium and small, triangular faces?
A positive family history and signs such as abnormal dentition, blue sclerae, ligament laxity, scoliosis, or bone bowing/fragility are helpful in diagnosing the case.
When is her appointment with her surgeon?
Keep me informed.
Bye.

[blayzmoon]

Hi, thanks for your comment. She is 6 years old. The dentist says osteogenesis imperfecta is a genetic disease and it can be given to the child by either parent but it can also be caused by a gene mutating by itself. It is usually carried from the parents but not always. She has an appoinment with Ortho on Friday so i will be requesting the testing including MRI. Thanks again!

[blayzmoon]

Blayz sometimes appears to have difficulty hearing (Don't all young kids!) but she has not been tested as we had no reason to test her until now. Both her eyes have a blue tint to them. Her face is triangular in shape. She is not short for her age though. I myself have terrible teeth (what i have left anyway) despite always taking good care of them. I have only broken a few bones in my life though, nothing big. My husband has decent teeth and also has broken only a few bones. They mentioned something about the laxity of her achilles tendon on one of her notes a few months back. The dentist said he coulnd not believe the ortho doctors missed it, it was quite obvious she has blue eyes. (Not obvious to me of course, but obvious to a doctor) Her appoinment is on Friday morning. I will be asking for the genetic testing as well as the MRI. They will most likely try to pat me on the head and tell me to go home, like they always do (typical military - so used to dealing with soldiers they have lost all feeling for a small child) but this time i won't beleaving until they do as i ask. Will post the results of any testing when we get them. Thanks again.

[JainMD]

Hi Blayz Moon,
What is your name Madam?
You can ask for DNA mutation analysis (blood test), which is available through specialized labs.
Dermal punch biopsy can be performed at a later stage to analyze collagen if routine diagnostic criteria are inconclusive.
Keep me informed.
Bye.

[blayzmoon]

Hello again,
My daughter has spent this week at the doctors office with both a pediatrician and an O.I. specialist. She has been diagnosed with O.I. plus dental. Thanks for all your help, answering all of my questions. Without your answers i would not have known which questions to ask. Asking questions is what led to my daughters confirmed diagnosis. Pauline and Blayz.

[JainMD]

Hi Pauline and Blayz,
How are you feeling now?
I am so glad and happy that our discussion and questions with each other has led to a confirmed diagnosis of your child. It deepens my confidence as a concerned clinician and a good paediatrician.
I would like to know what treatment management is being planned for her?
What about her investigations, have any results come?
Keep me informed if you have any queries.
Bye.

[blayzmoon]

Hi,
We are waiting on an appointment with a pediatric geneticist who specializes in O.I. Blayz will be attending her O.I. appointments outwith our area, at a specialist teaching hospital. (University of North Carolina) They suggested she could have yearly I.V. treatments with pamidronate, but that was just a suggestion as yet, until we see the genetics specialist we won't know for definate what will be happening. The O.I. specialist has suggested my sisters 3 children be tested as they also have a history similar to that of my daughter, but so far have been diagnosed with hypermobility of the joints. I will keep you posted on the results of further testing.
Thanks again!

[JainMD]

Hi Pauline,
I remember that in one of my post I had mentioned regarding biphosphanates and you had replied saying what is it and nobody has even told you about it.
Pamidronate belongs to same class of drugs.
Diphosphonates treatment (Pamidronate, alendronate, etc.) may improve (but will not normalize) bone density, decrease fracture frequency, and improve quality of life in children but not adults
Molecular treatments are a goal for the future.
A physical therapist should be involved with most children to assess their abilities and plan realistic goals, working to develop ambulatory potential and proceeding with appropriate seating.
Keep me informed.
Bye.

[blayzmoon]

Hello once again,
Blayz recently had some blood work done:
Neutrophils levels came back High at 8.0 and 76.0
(Doctor suggested it should have been 1.2-6.0, and the other should have been 30-50)
Alkaline Phosphatase levels came back high also at 173
(Doctor suggested it should have been 37-113)
Lymphocytes came back at 1.7 and low at 16.1 (Doctor suggested the first is normal 1.0-5.5, but second measurment should have been 25-46, hers was 16.1)
What does any of this mean?? Does it have anything to do with her O.I. or is this completely unrelated?
Thank you in advance for any help you can be.

[JainMD]

Hi,
How is your daughter doing?
High neutrophils suggest that she has contacted some infection, which can be either viral or bacterial.
High alkaline phosphatase is a part of her OI.
If neutrophils are high, lymphocytes would come down which again suggests that there is some infection which can be either bacterial or viral.
Does she have any fever? Does she have any coryza, cough of recent origin?
If yes then probably that would explain the condition and also the blood counts.
Keep me informed.
Bye.

[blayzmoon]

Hi,
So it is normal for a person with O.I. to have high alkaline phosphatase levels then? Will it be this way her whole life? and is this considered a sign/symptom of O.I.? When she had the blood taken she was not sick that we were aware of. She had had a fever around about that time but nothing to concern us.
Thanks again!

[JainMD]

Hi,
You need to understand when you are diagnosed with Osteogenesis Imperfecta you are bound to have fractures or bony deformities. In that case due to bony deformities or fractures alkaline phosphatase would be raised.
As bone turnover is more hence these bone turn over markers would be raised and these are excellent markers for monitoring.
No it is not considered a sign and symptom, but an association due to the pathology involved.
Exactly if she has fever the counts would have gone up high and the fever could have been due to viral fever.
Keep me informed if you have any queries.
You can visit the following URL for your reading.
http://www.orpha.net/data/patho/GB/uk-OI.pdf
Bye.

[blayzmoon]

Hi, Blayz just had a bone density scan. The results given to me were as follows:
The total body bone mineral density is calculated at 0.813 grams per centimeter squared which is 100% of the Z-score each matched value. The total bone mineral concentration is calculated at 921 grams and the bone mineral concentration per bone area is calculated at the 45th percentile in this child based on a lunar pediatric reference population.
Can you please tell me what this means?
Thank you!!