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Case of the Month

by Dr Noreen Norfaraheen Lee Abdullah MD (UKM), MMed Radiology (UKM), AM(Mal)

Answer to Case Of the Month 
Scurvy

Discussion of Findings
There is extensive periosteal elevation in the mid and lower femoral shaft and metaphyses. This indicates subperiosteal hemorrhage. The epiphyses is widely separated from the metaphyses and displaced forwards. No fractures observed. There is loss of bone density in the femur, tibia and fibula consistent with osteopenia.

Diagnosis: Scurvy

Differential diagnosis: Non accidental injury
Scurvy
This condition results from long-term deficiency of vitamin C in the diet. It is uncommonly seen nowadays but occasionally occurs in a child who has an aversion towards fruits and vegetables or chronically malnourished. For scurvy to develop, the Vitamin C deficiency must be present for a long time.

There are many signs associated with scurvy. Though not distinctly present in the above case, it is best discussed here for learning purpose. The pathological changes in scurvy occur as the result of depression of normal cellular activity in the bone. This results in cessation of normal bone formation. As a result, there is bone resorption and osteoporosis develops. At the growth plate, cartilage proliferation is decreased. Mineralization continues and this results in a wide dense zone of provisional calcification classically described as the white lines of Frankl. Similarly changes occur in the epiphyseal ossification center and known as Wimberger’s sign of scurvy. Sometimes a transverse band of lucency is seen at the bone subjacent to the zone of provisional calcification. This is referred as the Trummerfeld zone. It is a weak zone and tends to fracture. Marginal spurs may occur at the corner regions of the metaphyses and this is known as Pelkan’s spurs.

Though such signs are rare but we must be aware of them so that we can constantly look out for them. The most important thing when encountered with such a radiograph is to perform a skeletal survey. Scurvy tends to affect the regions of active endochondral bone growth. Therefore similar changes will be seen at the sternal ends of ribs, proximal end of humerus, distal end of radius and ulna and distal ends of tibia and fibula. Symptom and signs must be correlated such as bleeding diatheses and anaemia. The skeletal survey will record differential ages of fractures if the cause is non-accidental injury.
 
About the Author 
Dr Noreen, a Consultant Radiologist is currently with the Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.
 
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Last Updated:
Tuesday, 01 January 2008