Pediatric Musculoskeletal (MSK) X-ray OSCE

Table of Content

  1. Scurvy
  2. Rickets
  3. Osteopetrosis
  4. Gaucher's Disease
  5. Hypothyroidism
  6. Congenital Syphilis
  7. Lead poisoning

Masculoskeletal X-ray finidngs in Scurvey

Scurvy skeletal signs
Overview of skeletal signs in Scurvy

Pelken's spur
Pelken's spur

Ground glass opacities in

  1. The shaft of long bones
  2. Epiphyseal centers of ossifications.

Reason for GGO in Scurvy

Trabecular destruction and Atrophy of the trebeculae result in GGO. These are peculiarly noted arround knee joint.

Pencil like Cortex

Thin and dense Cortical bones. (diphyseal finding)

The white line of Frankel

Irregular but thickened white line at metaphysis in X-ray which represents zone of well calcified cartilage.

Remember these are seen in active scurvy and first radiological sign treatment of rickets

Wimbergers ring

Sclerotic ring of increased density around epiphysis.

Trummerfeld Zone

Zone of rarefaction under white line of metaphysis ( More specific). It is adjacent to frankel line.

The area represent debris of broken down bone trabeculae and connective tissue. It is also known as the scurvy line

Pelken Spur

Lateral prolongation of white line present at cortical end.

Musculoskeletal X-ray in advanced Scurvy

In advance disease the x-ray additionally shows Sub-periosteal haemorrhages with calcification


Signs of rickets
Image.3 - Signs in rickets
Rerefaction of bones in rickets
Image.4 - Notice Generalised rerefaction: source 3

Radiological finidings in Rickets

  1. Thickening of growth plate due to reduced calcification.
  2. Fraying - Due to weight-bearing the The edge of metaphysis looses its sharp border and becomes irregular
  3. Splaying- Due to weight-bearing, the metaphysis starts spreading out called as splaying.
  4. Cupping - Convex or flat edge of metaphysis changes to concave surface.
  5. Widening of distal end of metaphysis ( Growth plate)
  6. Generalised rerefaction

Radiological differences between skeletal findings of Rickets and Scurvy

white line of Frankel is a sign of healing Ricketswhite line of Frankel is sign of disease
The rachitic rosary is non-tenderScorbutic rosary is tender
Radiologically allegedly more severe changes in upper extremitiesRadiologically more severe changes in lower extremities.


Skeletal Xray in osteopetrosis
Fig.5 - Compare the densities of these two bones
Sandwich vertebra
Fig.6 - Notice Sandwich like appearance of vertebral bones

Skeletal X-ray finings in Osteopetrosis

  1. Generalized increase in bone density and clubbing of metaphysis.
  2. Called a marble bone due to increased density. ( more white/opaque)
  3. Erlenmeyer flask deformity ( read below in Gaucher's disease)
  4. Alternating dense and lucent bands produce a sandwich appearance to vertebral bodies.
  5. Bone-in Bone appearance.

Note that the more dense long bones are actually brittle and prone to recurrent pathological fractures

What is Bone in Bone appearance?

The term is used to describe bones that appear to have another bone within them. The differentials for bone-in bone appearance are

  1. Normal thoracic and lumbar vertebrae in neonates.
  2. Artifact.
  3. sickle cell disease/ thalassaemia /Gaucher disease
  4. chronic osteomyelitis
  5. scurvy
  6. Caffey disease
  7. osteopetrosis
  8. Lead poisoning
  9. Hypervitaminosis D
  10. leukaemia, metastases

Gauchers disease

Radiological findings are

  1. Bone is bone appearance.
  2. Erlenmeyer flask deformity.

What is Erlenmeyer flask deformity?

Erlenmeyer flask deformity
Fig.7 - Erlenmeyer flask deformity

Erlenmeyer flask deformity is not specific for Gaucher disease.

The sign is described as reduced constriction of the diaphysis and flaring of the metaphysis as a result of undertubulation.

Described classically in femoral bones and looks like a flat bottom flask used in chemistry.

It also means that the pathology occurred in the developing skeleton.

Differntial Diagnosis of Erlenmeyer flask deformity

  1. Gaucher disease
  2. Niemann-Pick disease (type B)
  3. Thalassaemia -especially if treated with desferoxamine.
  4. Sickle cell disease
  5. Chronic lead poisoning
  6. Osteopetrosis
  7. Achondroplasia


Skeletal X-ray finidings are

  1. Retardation of osseous development.
  2. Absence of distal femoral and proximal tibial epiphysis.
  3. Epiphysis often has multiple foci of ossification called as epiphyseal dysgenesis.
  4. Spine x-ray - Breaking of 12th and or 1st/2nd lumbar vertebrae
  5. Skull x-ray
    1. Large Fontanels
    2. Wide sutures
    3. wormian bones - Intersutural bones.
    4. Sella turcica -looks enlarged and round.
  6. Chest Xray
    1. Cardiac enlargement
    2. Pericardial effusion

Lead Poisoning

Skeletal X-ray finidings are

  1. Chronic lead poisoning shows lead lines in growing bones.
  2. They are not an early manifestation of toxic lead exposure.
  3. Lead lines usually occur at a blood level of more than 70-80 mcg/dL

What are Lead lines?

Bands of increased density (opaque) at metaphysis of tubular bones which are growing. They are Seen commonly in the proximal fibula and distal ulna.

Reason for apperance of lead line in proximal fibula and distal ulna

Growth is not as great as other long bones here.

Note that Burton’s line is a blue-purplish line on the gums seen in also chronic lead poisoning. It is caused by a reaction between circulating lead with sulfur ions released by oral bacterial activity, which deposits lead sulfide at the junction of the teeth and gums.

Congenital Syphilis

What is Wimberger sign ?

  1. It is pathognomic of congenital syphilis.
  2. Caused by Bilateral Metaphyseal demineralization of medial aspect of the proximal tibia.

Do not confuse with the Wimberger ring sign.

Other Findings

  1. Multiple sites of osteochondritis in the wrist, elbow, ankles, and knees, etc.
  2. Periostitis of long bones.

Further Reading

  1. Musculoskeletal X-ray - General principles
  2. Musculoskeletal X‐rays for Medical Students and Trainees 2017 Pdf book


  1. Source 1- Case courtesy of Dr Matt Skalski, From the case rID: 19946
  2. Source 2- Hussein A. Algahtani,a Abduljaleel P. Abdu,a Imad M. Khojah,b and Ali M. Al-Khathaamic, CC BY 2.5, via Wikimedia Commons
  3. Source 3- Frank Gaillard, CC BY-SA 3.0, via Wikimedia Commons


about authors

Shama Sowdagar | DNB (Pediatrics)

Shama has completed residency from Kanchi kamakoti Child Trust Hospital, Chennai and works as a Pediatrician

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