There is possible evidence that there was a fracture through the lesion on the distal and lateral aspect of the distal femoral metaphysis. This forced the bone to heal in valgus and with some shortening. This is the reason of limping. To have a better understanding of the possible diagnosis there will be necessary to have more details of the history, previous medical conditions, possibility of trauma even trivial, any pains in the area, what the mother observed etc.  

Dear dr/Osaid

 I think this patient had malignant tumor like Ostogenic sarcoma or ?? Ewing sarcoma

Possible diagnosis for this age is osteoblastoma, bone cyst, non ossified fibroma and from malignant part (although more common at later years) Ewing or Osteosarcoma. Infection must not be ruled out in the differential diagnosis.The diagnosis will be helped by the giving more information on present and past history taken from mother, clinical picture and potential trivial trauma.

Dear Mr. George Zafiropoulos & Dr. Nabil

Many thanks for your detailed reply, I`ve told the patient`s father to do MRI for his child`s femur and I`ll reply with a copy of it when it`s done. 

Regarding the Hx; there is no history of significant trauma/fall.

This is a pathologic fracture in process of healing and malunion with valgus of the  distal femur. Although a malignant blastoma is less probable (no osteolysis, no periosteal reaction) I would recommend biopsy. Any clinical, paraclinical signs of infection ?   

I would not worry with distal femur bone lesion. this is typical of cortical fibrous defect/non ossifing fibroma. it is typical benign lesion common in this age. 

I would suggest ct scanometry to measure femur length with precision. 

also mri of the hip could diangnose transient sinovitis of the hip. probably the most common cause of acure onset of limp in this age group. 

Thank you very much for the further information. We need to wait and review.

@Marcelo De Abreu: Yes, the localization is typical for non-ossifying fibroma, but I do worry about the endoosteal bone formation and the pathological fracture with malunion (not typical for non-ossifying fibroma). Transient hip synovitis is typical for the age, but it is less probable with the findings in the distal femur (double lesion ?).

From X ray; There is Leg length discrepancy (LLD) and valgus deformity in the right supracondylar  femoral region. Bone formation is more likely e fibrous cortical bone defect. 

Very many thanks for your comments, I`ve received the patient`s MRI (attached) 

Your comments will be appreciated! 

Full MRI: 

https://www.dropbox.com/s/ir4vy9zjifjlzel/Hasan%20MRI%204-1-2015.zip?dl=0

Dear Dr Osaid

Thank you for the images. The cuts are thick but the first impression from the pictures is that the soft tissues are not influenced and there is no clear reaction around the lesion, which looks benign (possibly a bone cyst which is healing or non ossified fibroma).

Seems that this fracture is an old event and there was potentially a pathological fracture in the area as there is visible at the lateral views that the initial anterior cortex is lying posteriorly as it was angulated in this direction with the apex at the lesion and there is re-modelling in front of it. The horizontal cuts show that at the distal area of the lesion there is a dibble (visible only in one slide). There is potentially a small degree of periosteal thickening but there is no acute reaction and marrow is inert.  

It is not clear if there was any trivial injury or if mother remembers anything. How was the delivery? Was the child breach or was mother's first child? How was the mobility of the limb immediately after birth? Was he limping even slightly when he started walking and this became more prominent for the last 2 months?

On top of this how is clinically the rotation of the right leg in comparison with the left, because looks like on the plain films that there is so rotation element (potentially internal on the right in comparison with the left) and this may be present in the MRI showing that the fracture involved the anterior and lateral aspect of the bone pushing the distal past in extension and posterior angulation as well as in valgus and internal rotation. This is possibly because the distal part of the bone pivoted around the medial intact cortex and healed in malposition.

So more clinical information will be necessary. To give back length need to correct the valgus deformity.

Hope that this may help.

In my opinion a  spontaneous correction of the valgus deformity is not expected. So  a correction osteotomy should be considered. That is why I still think biopsy and precise histological (microbiological ?) diagnosis is mandatory.  

I agree with Panayot on the histological and bacteriological investigation as an operation will be necessary.

Probably the bone lesion in the distal metaphyseal region of the right femur is a fibrous cortical defect and I consider a radiological finding. Limping is due the valgus of the right femur and I think the distal lateral femoral physeal plate is compromised. It may have been a SHarris type V injury

Salter-Harris Type 5 is a very rare injury, and the combination with the present lesion in the distal meta-diaphyseal area of the femur seems to me to be extremely uncommon.Furthermore, SH Type 5 is a whole physis damage, so later deformities   in the coronal or sagittal plane are not typical. Also, no trauma in the past  is reported. I think we would have to focus on the present lesion and its sequelae.

probably need more history. also need to always keep child abuse in the back of one's mind whenever there is a fracture without reported trauma.

This pathologic lesion may have influence in the process of vascularisation of supracondylar femoral region and as a sequelae asymmetrical growth in the distal sypracondylar physis. In x - ray pictures there is no signs of distal physeal  change (damage) for this asymmetrical growth. I am agree with Panayot that no chance for spontaneous correction of this deformity and histological and bacteriological investigation are nedded. .

There is no evidence of any epiphyseal injury, so Salter Harris classification is not a valid measure. The fracture is done through the pathological lesion and there is an element of rotation resulting to the valgus position and due to the produced angle the bone became shorter (it is known from geometry that an angled line is shorter that a straight line when they have the same length.

The properties of the lesion are not known but seems to be benign as there is no visible periosteal reaction on the MRI. The correction has to be surgical and because of this opportunity bone investigations (histology and bacteriology) can be done with ease.

Child or Domestic abuse is a phenomenon more commonly reported in western culture and as the child is attending Gaza University Hospital I would suggest that in that culture is more common for people to be more attending to their children although children themselves are more interactive with their siblings and accidents between them may happen. Inexperience between the siblings or a "hidden event" by one of the other children can be explained as child abuse in the western mind.

It is a fibrocartilaginous dysplasia

Treatment could be done with a femoral distal valgus osteotomy...if the non surgical follow up did no improve the varus deformity during previous 1 year.

@Dr. Juan Abril:  You certainly mean varus osteotomy and not valgus ? The present  deformity  is valgus, not varus. Lapsus calami ? 

I follow Panayot: biopsy sould be performed before other treatments are applied (brace/operation). The knee has gone in valgus-deformity, therefore the limping with relative shortening of leg length.

I believe that as there  is in Valgus deformity, a varus osteotomy would be necessary and not a valgus. Possibly the entry above is written by mistake.

Yes. Sorry. Varus osteotomy is the correct procedure

Dear Mr. George Zafiropoulos, Dr. Panayot Tanchev, Dr. Nelson Elias, Dr. Vandana Prasad, Dr.Cen I. Bytyqi, Dr.Juan carlos Abril, Dr.Dietrich Klueber 

Many thanks for your replies.. 

The delivery was uneventful and the limping started to be noticed by the parents only 2-3 months ago. They are very careful with their child and it`s rare to see here any form of child abuse! 

So, most of you agree that it`s mostly benign lesion and it need excision & biopsy with varus osteotomy to correct the deformity!

What is the optimal time for the operation? Is there any possibity for conservative management with follow up with MRI 1-2 months later? 

N.B: I`m attaching a photo for the child`s limbs exposed ..

Thanks

The problem is that the deformity is not on the movement plane (for example anterior angulation) and so there is no possibility for this to improve. So non operative treatment is not possible and this will create potentially increasing of the valgus deformity. 

From the photo there is evidence of rotation (patella is externally rotated in comparison with the left leg). A more detailed CT scan with 3D reconstruction would be beneficial if it is available for the pre-op planning.

Operation would be better as early as possible as the child will tolerate plaster better and it would be easier for the parents to carry him around. Metal work could be also a small plate which will be removed few months down the road, so plaster will be necessary. Also stabilisation (if plaster is thought to be difficult to be managed after discussion with the parents) can be achieved with external fixator. This way it would be easier to correct rotation even at a later stage, if optimal position will not be possible to be achieved initially. Defect can be left alone after biopsy or filled with allograft if available.

I agree with George's considerations. I would prefer 2-staged surgery. First, biopsy (needle ?) to verify the diagnosis and exclude local infective focus. Then  varus osteotomy with eventual excision of the lesion and plating (additional grafts if defect is too big after excision).

The osteotomy could be performed if after 1 year follow up the spontaneus improvement was not present.

Biopsy is  mandatory if you dont have sure of diagnosis, but in this  case is very clear..is a fibrocartilaginous displasy. You never must performed an surgical operation if you think that infection or tumor lesion is present.

We would performed the osteotomy with angular y rotational correction..always after lesion cartilaginous resection. No bone graft is necessary because is a young children. And it could be use  k wire for bone fixation and in this way a plaster would be necessary at least 4 weeks.

Fibrocartilaginous dysplasia is probable indeed. But I strongly insist on a histological examination and diagnosis because one should make a differential diagnosis with osteoblastoma, enchondroma, desmoplastic fibroma, fibrosarcoma, histiocytoma and solitary bone cyst. The radiological diagnosis in this case is more difficult based on the reparative changes after the pathological fracture. As far as the use of grafts is concerned, I would not reject it with such an absolute certainty because one can not say in advance how large will be the resection area. The more so that you should perform here a plus osteotomy which will make a bigger defect.

 dr. Tanchev..certenly. But the resection in case of dysplasia, could be only afected tthe external cortical bine and so no bone graft should be necessary. Distal femur could be impacted in the resectuon focus and only 2 or 3 k wire could be introduce for stability.

Dr. Abril, impaction of osteotomy surfaces after resection will result in a significant shortening of the leg. Fixation with K-wires and plaster is possible, but unstable. I would not hesitate to perform plus osteotomy with plating. If the defect after curettage or resection  is too big grafting is necessary.   

The use of graft may or may not be necessary according the produced defect. The exact anatomical reduction (referencing the length and the impaction use or not) may be considered after pre-op analysis and planning of the potential length which may be achieved after the leg placed at the straight position. If the length which will be achieved is the exact length of the other leg, impaction may be considered as the osteotomy's vascularisation will stimulate length growth. On the other hand if the shortening will not be sufficient then anatomical reduction as for length and rotation should be obtained so the accumulated due to the osteotomy's vascularity length would help the correction for the future leg length. Please do not forget the rotation. For fixation wires may be helpful if impaction would be stable and no graft would be necessary and that parents are happy with the plaster. If the gap is such that is necessary to use graft or if osteotomy is unstable then a plate or external fixator can be used.

I was grazing through Kleiner's Human Biochemistry this morning with coffee and this question came to mind when reading about avitaminosis (vitamin D) and Rickets.  Given the dense lines at the metaphyses in the x-rays I am thinking there are three possible causes of this child's condition.  Rickets, hypoparathyroidism or quite possibly lead poisoning.   

Vitamin D hypervitamintosis maybe... 

 hello all,

given the benign nature of the lesion through the x ray and MRI appearance. and the intact growth plate and the young age of the patient, we may go toward temporary distal medial femoral hemiepiphysiodesis. and later we can assess LLD and deal with it.