Abstract
Objective
Heel pain in children and secondary MR imaging (MRI) of the hindfoot have been increasing in incidence. Our purpose is to illustrate the, previously unreported, MRI stages in development of the posterior calcaneal apophysis, with attention to imaging pitfalls. This should aid in distinguishing normal growth from true disease.
Material and methods
Consecutive ankle MRIs in children <18 years, from 2008–2014, were subdivided into 0≤5, 5≤10, 10≤15 and 15≤18 age groups and retrospectively reviewed for development of the calcaneal apophysis.
Results
204 ankle MRI studies in 188 children were identified. 40 studies were excluded with final cohort of 164 studies in 154 patients (82 boys, 72 girls). The calcaneal apophysis was cartilaginous until age 5. Foci of decreased as well as increased signal were embedded in cartilage, prior to ossification. Early, secondary ossification centers appeared in plantar third of the apophysis in 100 % of children by age 7. Increased T2 signal in the ossifications was seen in 30 % of children. Apohyseal fusion began at 12 and was complete in 78 % of 14≤15 year olds and in 88 % of 15≤18 year olds. Curvilinear low signal in the ossification centers, paralleling, but distinguished from growth plate, and not be confused with fracture line, was common.
Conclusion
Development of the posterior calcaneus follows a unique sequence. Apophyseal fusion occurs earlier than reported in the literature. Familiarity with this maturation pattern, in particular the apophyseal increased T2 signal and the linear low signal paralleling the growth plate, will avoid misinterpreting it for pathology.
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References
Sever JW. Apophysitis of the os calcis. NY State J Med. 1912;95:1025–9.
James AM, Williams CM, Luscombe M, Hunter R, Haines TP. Factors associated with pain severity in children with calcaneal apophysitis (sever disease). J Pediatr. 2015;167(2):455–9.
Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987;7(1):34–8.
Ogden JA, Ganey TM, Hill JD, Jaakkola JI. Sever’s injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop. 2004;24(5):488–92.
Katz JF. Nonarticular osteochondroses. Clin Orthop Relat Res. 1981;158:70–6.
Ogden JA. Foot in skeletal injury in the child. 3rd ed. New York: Springer; 2000. p. 1091–101.
Perhamre S, Lazowska D, Papageorgiou S, Lundin F, Klassbo M, Norlin R. Sever’s injury: a clinical diagnosis. J Am Podiatr Med Assoc. 2013;103(5):361–8.
Wiegerinck JI, Zwiers R, Sierevelt IN, Van Weert HC, van Dijk CN, Struijs PA. Treatment of calcaneal apophysitis: wait and see versus orthotic device versus physical therapy—a pragmatic therapeutic randomized clinical trial. J Pediatr Orthop. 2015. PMID: 25985369.
Perhamre S, Lundin F, Klassbo M, Norlin R. A heel cup improves the function of the heel pad in Sever’s injury: effects on heel pad thickness, peak pressure and pain. Scand J Med Sci Sports. 2012;4:516–22.
Walling AK, Grogan DP, Carty CT, Ogden JA. Fractures of the calcaneal apophysis. J Orthop Trauma. 1990;4:349–55.
Ross SE, Caffey J. Ossification of the calcaneal apophysis in healthy children. Stanford Med Bull. 1957;15(3):224–6.
Liberson A, Lieberson S, Mendes DG, Shajrawi I, Ben Haim Y, Boss JH. Remodeling of the calcaneus apophysis in the growing child. J Pediatr Orthop. 1995;4(1):74–9.
Volpon JB, De Carvalho Filho G. Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg. 2002;122(6):338–41.
Shabshin N, Schweitzer ME, Morrison WB, Carrino JA, Keller MS, Grissom LE. High-signal T2 changes of the bone marrow of the foot and ankle in children: red marrow or traumatic changes? Pediatr Radiol. 2006;36(7):670–6.
Laor T, Jaramillo D. MR imaging insights into skeletal maturation: what is normal? Radiology. 2009;250(1):28–38.
Scheuer L, Black S. The lower limb in developmental juvenile osteology. San Diego: Academic; 2000. p. 374–80.
Kwong S, Kothary S, Poncinelli LL. Skeletal development of the proximal humerus in the pediatric population: MRI features. Am J Roentgenol. 2014;202(2):418–25.
Chauvin NA, Jaimes C, Laor T, Jaramillo D. Magnetic resonance imaging of the pediatric shoulder. Magn Reson Imaging Clin N Am. 2012;20(2):327–47.
Jarmaillo D, Waters PM. MR Imaging of the normal developmental anatomy of the elbow. Magn Reson Imaging Clin N Am. 1997;5(3):501–13.
Varich LJ, Laor T, Jaramillo D. Normal maturation of the distal femoral epiphyseal cartilage: age-related changes at MR imaging. Radiology. 2000;214(3):705–9.
Moore SG, Dawson KL. Red and yellow marrow in the femur: age-related changes in appearance at MR imaging. Radiology. 1990;175:219–23.
Murphy DT, Moynagh MR, Eustace SJ, Kavanagh EC. Bone marrow. Magn Reson Imaging Clin N Am. 2010;18(4):727–35.
Zawin JK, Jaramillo D. Conversion of bone marrow in the humerus, sternum, and clavicle: changes with age on MR images. Radiology. 1993;188(1):159–64.
Garn SM, Sandusky ST, Nagy JM, McCann MB. Advanced skeletal development in low-income Negro children. J Pediatr. 1972;80:965–9.
Acknowledgements
We thank Christopher Morley MD, Chimere MBa-Jones MD and Annie Wang for their help with gathering the data.
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Rossi, I., Rosenberg, Z. & Zember, J. Normal skeletal development and imaging pitfalls of the calcaneal apophysis: MRI features. Skeletal Radiol 45, 483–493 (2016). https://doi.org/10.1007/s00256-015-2320-4
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DOI: https://doi.org/10.1007/s00256-015-2320-4