Short Report
A head within a head sign: a manifestation of healing nutritional rickets
Tropical Doctor 2014, Vol. 44(3) 169–170 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514530918 tdo.sagepub.com
Anil Agarwal1 and Rachna Agarwal2
Abstract The epiphyseal perichondrium is calcified during the rachitic healing process and visible radiologically as ‘a head within a head’ around the proximal femoral epiphysis in young children. Seen in isolation, these radiographs can pose diagnostic dilemmas.
Keywords Rickets, proximal femoral epiphysis
Short report Nutritional rickets is a prominent health problem in several African, Middle East and Asian countries with prevalence rates as high as 10–70%.1 Being a disorder of open growth plates, the radiological focus is mainly on sites with the fastest growing bones, e.g. radius and ulna at the wrist, distal femur at the knee, distal tibia at the ankle, proximal femur at the hip, proximal humerus and anterior ends of ribs.2 The hip region has an active growing epiphysis throughout childhood and shares the burden of this generalized metabolic disease. The presentation of hip complaints may be delayed walking, waddling, limp, pain, limb length discrepancies and so on.3 Radiological manifestations of the rachitic hip radiological manifestations can be quite variable and influenced by the type and severity of nutritional deficiency, body response and duration of treatment (Figure 1a–e; see following page). The epiphyseal perichondrium is calcified during the healing process and visible radiologically as ‘a head within a head’ around the proximal femoral epiphysis in young children (Figure 1e). An awareness of these plain
radiological findings can lead to the correct diagnosis when used with a careful history, physical examination and biochemical investigations. Most children show recovery following appropriate calcium and vitamin D supplementation. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Prentice A. Nutritional rickets around the world. J Steroid Biochem Mol Biol 2013; 136: 201–206. 2. Shore RM and Chesney RW. Rickets: Part II. Pediatr Radiol 2013; 43: 152–172. 3. Agarwal A, Gulati D, Rath S and Walia M. Rickets: a cause of delayed walking in toddlers. Indian J Pediatr 2009; 76: 269–272.
1 Specialist, Department of Pediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, India 2 Associate Professor, Department of Obstetrics and Gynaecology, UCMS and GTB Hospital, India
Corresponding author: Anil Agarwal, 4/103, East End Apartments, Mayur Vihar Ph-1 Ext., Delhi 110096, India. Email: [email protected]
Downloaded from tdo.sagepub.com at MCMASTER UNIV LIBRARY on June 30, 2015
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Figure 1. Sequential treatment hip radiographs in a 3-year-old child with severe nutritional rickets. (a) At presentation. Washed out and eroded appearance of proximal femur and acetabulum due to severe demineralization. (b) Three weeks following treatment: mineralisation is now obvious. The medial neck region in both hips shows pathological fractures. (c) Twelve weeks following treatment: there is coxa vara deformity in right hip. (d) Sixteen weeks following treatment: calcification in epiphyseal perichondrium. (e) Twenty weeks following treatment: Distinct head within head sign is seen in both hips.
Downloaded from tdo.sagepub.com at MCMASTER UNIV LIBRARY on June 30, 2015
A head within a head sign: a manifestation of healing nutritional rickets
Tropical Doctor 2014, Vol. 44(3) 169–170 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514530918 tdo.sagepub.com
Anil Agarwal1 and Rachna Agarwal2
Abstract The epiphyseal perichondrium is calcified during the rachitic healing process and visible radiologically as ‘a head within a head’ around the proximal femoral epiphysis in young children. Seen in isolation, these radiographs can pose diagnostic dilemmas.
Keywords Rickets, proximal femoral epiphysis
Short report Nutritional rickets is a prominent health problem in several African, Middle East and Asian countries with prevalence rates as high as 10–70%.1 Being a disorder of open growth plates, the radiological focus is mainly on sites with the fastest growing bones, e.g. radius and ulna at the wrist, distal femur at the knee, distal tibia at the ankle, proximal femur at the hip, proximal humerus and anterior ends of ribs.2 The hip region has an active growing epiphysis throughout childhood and shares the burden of this generalized metabolic disease. The presentation of hip complaints may be delayed walking, waddling, limp, pain, limb length discrepancies and so on.3 Radiological manifestations of the rachitic hip radiological manifestations can be quite variable and influenced by the type and severity of nutritional deficiency, body response and duration of treatment (Figure 1a–e; see following page). The epiphyseal perichondrium is calcified during the healing process and visible radiologically as ‘a head within a head’ around the proximal femoral epiphysis in young children (Figure 1e). An awareness of these plain
radiological findings can lead to the correct diagnosis when used with a careful history, physical examination and biochemical investigations. Most children show recovery following appropriate calcium and vitamin D supplementation. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Prentice A. Nutritional rickets around the world. J Steroid Biochem Mol Biol 2013; 136: 201–206. 2. Shore RM and Chesney RW. Rickets: Part II. Pediatr Radiol 2013; 43: 152–172. 3. Agarwal A, Gulati D, Rath S and Walia M. Rickets: a cause of delayed walking in toddlers. Indian J Pediatr 2009; 76: 269–272.
1 Specialist, Department of Pediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, India 2 Associate Professor, Department of Obstetrics and Gynaecology, UCMS and GTB Hospital, India
Corresponding author: Anil Agarwal, 4/103, East End Apartments, Mayur Vihar Ph-1 Ext., Delhi 110096, India. Email: [email protected]
Downloaded from tdo.sagepub.com at MCMASTER UNIV LIBRARY on June 30, 2015
170
Tropical Doctor 44(3)
Figure 1. Sequential treatment hip radiographs in a 3-year-old child with severe nutritional rickets. (a) At presentation. Washed out and eroded appearance of proximal femur and acetabulum due to severe demineralization. (b) Three weeks following treatment: mineralisation is now obvious. The medial neck region in both hips shows pathological fractures. (c) Twelve weeks following treatment: there is coxa vara deformity in right hip. (d) Sixteen weeks following treatment: calcification in epiphyseal perichondrium. (e) Twenty weeks following treatment: Distinct head within head sign is seen in both hips.
Downloaded from tdo.sagepub.com at MCMASTER UNIV LIBRARY on June 30, 2015
