View source for Paper - Radiographic studies of the metacarpal and metatarsal bones in children (1939)

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=Radiographic Studies of the Metacarpal and Metatarsal Bones in Children=

By K. Posener, E. Walker and Graham Weddell

From the Institute of Anatomy and Embryology, University College, London


==Introduction==

This paper is the first of a series devolving from the periodic radiographic examination of 200 normal primary school children. The study was inaugurated by the late Prof. H. H. Woollard in an attempt to determine the part played by nutrition in the maturation of bones, and to divorce this, if possible, from other factors. The present paper is concerned with the appearance of epiphysial irregularities such as true double or so-called “‘pseudo-epiphyses”’ in metacarpal and metatarsal bones, which, it was thought, might shed some light upon this problem, since an increase in the incidence of pseudo-epiphyses has been recorded in cases of retarded growth (Siegert, 1910; Rochlin, 1927). True supernumerary epiphyses have a separate centre of ossification. Pseudo-epiphyses arise from a diaphysial extension into the cartilaginous extremity of the bone (Uffelmann, 1863). In the early stages of development a rod of osteoblastic tissue arising from the metaphysis invades the chrondroepiphysis. The distal part of this rod enlarges, so that later the ossified shaft appears to be surmounted by a mushroom-shaped cap. The connecting stalk may be narrow, or it may be so thick that it almost completely supplants the intervening cartilaginous ring. Thus the radiographic appearances vary from well-marked marginal incisions to shallow indentations of the bony cortex (Pl. I, fig. 1). When the connecting stalk is thin, it is sometimes difficult to discriminate in X-ray pictures between a true and a pseudo-epiphysis. This is especially the case where the shapes of the adjacent bony margins lead to inevitable overlapping of the shadows, as frequently occurs in the first metatarsal. On the other hand, slight degrees of pseudo-epiphysial formation must be differentiated from linear brightenings associated with the development of articular facets which may occur at the extremities of the metacarpals.

==Method==

The hands and feet of children from 4 to 8 years were examined radiographically at intervals of 6 months, for a period of 18 months. For the purposes of the present study, radiographs of 100 cases were selected. General clinical and dental examinations, including measurements of height, weight and muscular power, were also carried out. A vitamin C saturation test was performed, in order to determine whether low storage values had any influence on bone maturation. The children were given orally 100 mg. of ascorbic acid, and the amount of vitamin C excreted in the urine after 2-3 hr. was determined.

==Findings==

Undoubted true double epiphyses were only seen in two cases, the supplementary epiphysis being in both at the distal end of the 1st metatarsal. Pseudo-epiphyses, on the other hand, were common. They were seen in 96 % of the children’s hands.

Table I. Percentage incidence of pseudo-epiphyses in hands and feet of children

lst 2nd 3rd 4th 5th Metacarpals 81 52 1 2 57 Metatarsals 57 0 0 0 1

The irregularities recorded were nearly always bilateral. In two cases pseudo-epiphyses were observed on one side only. It has been stated (Stettner, 1981) that the radiographic markings of pseudo-epiphyses can persist for many years. In a number of cases the metacarpal pseudo-epiphyses had undergone considerable changes even in the comparatively short period of 18 months, some of them becoming more, some less marked, and others disappearing completely.

Table II. Changes in the percentage incidence of pseudo-epiphyses after eighteen months Appear more Appear less No longer

marked marked evident lst metacarpal 5 _- 5 2nd ” 17 —_ 12 3rd ” No change 4th ” No change _ Sth ” _— 8 _—


Comparison between the radiographic findings and the height, weight, muscular power and dental examinations showed no correlation between pseudo-epiphysial formation and the general nutritional state of the children as judged by these standards. In two children with mild degrees of Frélich’s syndrome there were no pseudo-epiphyses. In seven children with slight clinical signs of rickets (bowed tibiae and enlarged costochondral junctions) there was no increased incidence. This is in agreement with other observers (Josefson, 1916; Hasselwander, 1921; Koehler, 1935). In almost all the children a remarkably low level of vitamin C storage was found. This was also unrelated to the nutritional status as exemplified both by the clinical findings and the radiographic appearances.

==Discussion==

The percentages in Table I are in accordance with previous statistics. Stettner (1931), who published figures from 538 cases, found approximately the same percentage of pseudo-epiphyses and a similar distribution. The preponderance of the 1st metacarpal and metatarsal is striking. The 2nd and 5th metacarpals figure next with nearly equal frequency, while the 3rd and 4th metacarpals seldom show pseudo-epiphysial formation. The 2nd—5th metatarsals remain almost entirely free. The distribution seems to follow a definite pattern, for which up to now no satisfactory explanation has been offered. Possibly the appearance of these irregularities could be correlated with the relatively extensive mobility of the Ist, 2nd and 5th fingers and the great toe. Uffelmann believed that the 1st metacarpal represents a combination of a phalanx and a metacarpal, and suggested that this might explain the frequency of pseudoepiphyses in this bone. However, this would not explain the appearance of pseudo-epiphyses in the other bones.

Stettner observed in another series that, while on excluding the 1st metacarpal one-third of all ‘‘normal” children showed pseudo-epiphysial formation, two-thirds of all those “congenitally stigmatized” (e.g. with congenital dislocation of the hip), and about half the number of those with “‘exogenetic”’ diseases, showed the condition.

From these findings the author concluded that any early damage to the embryo may be reflected later in the formation of a large number of pseudoepiphyses. That he should have excluded the Ist metacarpal from his statistics diminishes the significance of his results. Notwithstanding the absence of definitely labelled pathological material in our series and the small numbers examined, from our observations we see no reason to associate an occurrence so common as pseudo-epiphysial formation with congenital or endocrine disturbances.

Koehler (1912) has suggested that the occurrence of either true or pseudoepiphyses in man might be due to the appearance of osteogenetic characters suppressed during evolution, and points to the well-known fact that in slowly growing sea-mammals (seal, walrus and whale) true double metacarpal epiphyses occur regularly. Monteiro & Carvalho (1938) have described a case in which they found radiographically a complete set of true double epiphyses in a healthy child. Thus, since neither nutritional factors nor pathological processes appear to influence the appearance of pseudo-epiphyses, a true genetic mechanism may be postulated. This hypothesis, which can only be solved by familial research on a large scale, has not so far been put to the test.

==Summary and Conclusions==

# A statistical analysis of the number of pseudo-epiphyses appearing in the metacarpal and metatarsal bones of one hundred children between the ages of 4 and 8 years has been made.
# Nocorrelation could be found between the incidence of pseudo-epiphyses in metacarpal and metatarsal bones and the nutritional status of children as determined by height, weight, amount of dental caries and muscular power.
# Pseudo-epiphysial formation does not appear to be correlated with vitamin deficiency or endocrine disturbances.


==References==

HAsSELWANDER (1921). Anat. Anz. 54, 199.

JOSEFSON (1916). Fortschr. Rontgenstr. 24, 266.

KOEHLER (1912). Miin. Med. Wschr. 41, 2229.

—— (1935). Réntgenology, pp. 26-7. London: Bailliére, Tindall and Cox. Monrerro & CaRVALHO (1938). Fol. anat., Coimbra, 18, (4), 1.

Rocutin (1927). Z. ges. Anat. 1, Z. Anat. EntwGesch. 82, 354.

SIEGERT (1910). Ergebn. inn. Med. Kinderheilk. 6, 565.

STETTNER (1931). Z. Kinderheilk. 51, 459.

UFFELMANN (1863). Monograph, Gottingen.


==Explanation of Plate I==

Fig. 1. Pseudo-epiphyses in A, base of 2nd metacarpal; B, base of 2nd metacarpal; C, distal end 2nd phalanx ring finger; D, distal end 1st metatarsal. Fig. 2. The pseudo-epiphysis at the base of the 2nd metacarpal is attached to the shaft by a thin

stalk. Fig. 3. Pseudo-epiphyses at the bases of the 2nd and 5th metacarpals and distal end of Ist metacarpal. Fig. 4. True supernumerary epiphysis at the distal end of the Ist metatarsal.

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