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As opposed to just a decade ago, the study of congenital syndromes is no longer an exercise in the rote memorization of seemingly disconnected syndromes. Instead, the unveiling of the intricacies of the genetic code has made apparent relationships among many inborn syndromes that had been previously unsuspected. What has emerged is that a relatively few genes are the cause of a multitude of syndromes, and by grouping syndromes and dysplasias into families based on the gene at fault, a taxonomy has emerged and has allowed a framework within which we can understand the relationships among a number of dysplasias and syndromes.
An abridged form of the International Skeletal Dysplasia Society skeletal dysplasia classification serves as the organization of this chapter ( Box 132.1 ). The full nosology text can be found at http://isds.ch/uploads/pdf_files/Nosology2010.pdf (accessed December 12, 2016). The major genetic families are presented with a short description of the salient unifying characteristics of the diseases within each group. When known, the gene and protein involved are considered and the impact of the mechanism of action discussed. The major members of each group are then expanded on to provide a clear picture for the reader.
Thanatophoric dysplasia type 1 and 2
Homozygous achondroplasia
Achondroplasia
Hypochondroplasia
Achondrogenesis type 2
Spondyloepiphyseal dysplasia congenital
Kniest dysplasia
Stickler syndrome type 2
Marshall syndrome
Oto-spondylo-mega-epiphyseal dysplasia
Achondrogenesis type 1b
Diastrophic dysplasia
Multiple epiphyseal dysplasia: Multilayered patellae/brachydactyly/clubfeet
Oto-palato-digital syndrome type 1 and 2
Larsen syndrome
Metatropic dysplasia
Spondylometaphyseal dysplasia Koslowski type
Short rib-polydactyly
Asphyxiating thoracic dysplasia
Chrondroectodermal dysplasia
Multiple epiphyseal dysplasia
Pseudoachondroplasia
Jansen-type metaphyseal chondrodysplasia
Schmid-type metaphyseal chondrodysplasia
McKusick-type metaphyseal chondrodysplasia
Shwachman-Diamond dysplasia
Spondyloenchondromatosis
Trichorhinophalangeal syndrome types I and II
Acromesomelic dysplasia of Maroteaux
Dyschondrosteosis
Campomelic dysplasia
Rhizomelic type
Osteopetrosis
Pyknodysostosis
Osteopoikilosis
Osteopathia striata
Melorheostosis
Craniodiaphyseal dysplasia
Craniometaphyseal dysplasia
Pyle disease
Osteogenesis imperfecta
Hypophosphatasia
Hunter syndrome or Hurler syndrome
Morquio syndrome
Mucolipidosis type II (I-cell disease)
Hajdu-Cheney dysplasia
Marfan syndrome
Congenital contractural arachnodactyly
Proteus syndrome
Cleidocranial dysplasia
Currarino triad
Rubinstein-Taybi syndrome
Poland anomaly
Brachydactyly A-E
Brachmann-De Lange syndrome
Holt-Oram syndrome
VATER/VACTERL
Klinefelter syndrome
Trisomy 13
Trisomy 18
Trisomy 21
Turner Syndrome (chromosome X monosomy)
VACTERL, Vertebral, anorectal, cardiac, tracheoesophageal, renal, limb.
In this chapter, the terms syndrome and dysplasia are used somewhat loosely. A syndrome is a set of characteristic findings that occur together and suggest a particular diagnosis, although the cause may not be known. A dysplasia is a set of characteristic findings in which the cause and effect are known. The distinction now has lost its value, as the cause of many “syndromes” are now known, and the term dysplasia is used to indicate not just purely a grouping of symptoms but the actual disease entity.
In the history of the delineation of many of the specific skeletal dysplasias, radiologic assessment plays a major role. By using an orderly approach to the radiographic analysis, the general type of the dysplasia may be elucidated. Many of the skeletal dysplasias and syndromes have distinctive radiographic features that will allow an exact diagnosis when even one of those distinctive features is identified and used as a search criterion in textbooks on skeletal dysplasia. Two such texts are Taybi and Lachman's Radiology of Syndromes, Metabolic Disorders and Skeletal Dysplasias , which includes an excellent gamuts section, and Bone Dysplasias, An Atlas of Genetic Disorders of Skeletal Development by Spranger and colleagues, in which the images are particularly helpful. In the online version of Taybi and Lachman's book, the gamut search may be built iteratively, with the diagnoses becoming more selective as findings are added to the search criteria. Internet searches can also be performed on the Online Mendelian Inheritance in Man database, which is accessed through the US Library of Medicine portal at http://www.ncbi.nlm.nih.gov/pubmed/ .
Micromelia is overall shortening of the extremities. Rhizomelia is relative shortening of the femurs and humeri. Mesomelia is relative shortening of the radii, ulnae, tibiae, and fibulae. Acromelia is relative shortening of the bones of hands and feet.
Classification of the shortened appendicular segment is helpful for diagnosis. Rhizomelia may be very helpful to confirm the specific diagnosis of the rhizomelic form of chondrodysplasia punctata. Very significant mesomelia suggests a group of specific disorders loosely classified as the mesomelic dysplasias. Acromelia is found in many disorders; when it occurs by itself, several specific dysplasias are suggested, including acrodysostosis, acromicric dysplasia, or pseudohypoparathyroidism.
The pattern of brachydactyly may facilitate diagnosis. For instance, brachydactyly type E manifests with variable shortening of the metacarpals and distal phalanges, and brachydactyly type A4 manifests with shortening restricted to the second and fifth middle phalanges. Even the absence of acromelia may be helpful. The lack of significant hand and foot shortening is a significant feature of spondyloepiphyseal dysplasia congenita (SEDC), a type 2 collagenopathy.
If epiphyseal ossification is delayed or if the ossified epiphyses are very small, irregular for age, or both, then an epiphyseal dysplasia of some sort is present. Carpal and tarsal bones are often affected. In diseases that can be considered pure epiphyseal dysplasias such as multiple epiphyseal dysplasia (MED) and pseudoachondroplasia, carpal and the tarsal bones are markedly crenellated and small ( Fig. 132.1 ). Another excellent location for epiphyseal analysis is the ring apophyses of the vertebral bodies, which exhibit delayed and irregular epiphyseal ossification in epiphyseal dysplasia. Central anterior vertebral body protrusions (central tongues or beaking) noted in Morquio syndrome and pseudoachondroplasia are also disorders related to abnormalities of the ring apophyses.
Fraying and irregularity of the physes and abnormal flaring of the metaphyses indicate disturbed endochondral ossification. Marked irregularity of the physes is characteristic of the pure metaphyseal dysplasias such as metaphyseal dysplasia, Jansen or Schmid type. When the metaphyses are merely flared and the physes are fairly normal, endochondral ossification may be slowed, but the actual process of endochondral ossification progresses normally. This occurs in achondroplasia. The metaphyses are flared, whereas the physis and the zone of provisional calcification (ZPC) are sharply defined ( Fig. 132.2 ).
Rickets also disturbs the physis. In rickets, physeal abnormalities lead to the classic appearance of metaphyseal cupping and fraying. Except in healing rickets, the ZPC is inapparent. In metaphyseal chondrodysplasias, the ZPC is present, although it is markedly irregular ( Fig. 132.3 ). Analysis of the sclerotic line of the ZPC is frequently an excellent differentiating feature. Other factors include prominent osteopenia in rickets with blurring of the trabeculae; clinical data are also very helpful.
Diaphyseal abnormalities primarily include bent bones and thickened sclerotic bones. The classic bent bone dysplasia is campomelic dysplasia. Others include hypophosphatasia and kyphomelic dysplasia. Thickened and sclerotic diaphyseal cortices may indicate one of the craniotubular dysplasias.
Decreased height of the vertebral bodies is termed platyspondyly . The lumbar vertebral bodies are the best level to analyze compared with the cervical level, especially in infancy. The cervical vertebral bodies tend to appear relatively hypoplastic compared with other levels in the normal infant. This is because ossification occurs later in cervical vertebral bodies compared with vertebral bodies elsewhere. In addition to platyspondyly, other vertebral body changes are important. In the lumbar spine in normal children, the interpediculate distance usually widens on a frontal film moving inferiorly. Inferior narrowing of the interpediculate distance is a feature of fibroblast growth factor receptor 3 (FGFR3) abnormalities such achondroplasia and thanatophoria.
Anisospondyly is when the vertebral body shape varies wildly ( e-Fig. 132.4 ). Multiple ossification centers may also be present. Although rare, this is a specific finding in dyssegmental dysplasia.
Bone mineral density should be assessed by not only examining the actual “whiteness” of bones but also by determining the relative thickness of the cortices relative to the medullary cavity and the coarseness of the trabeculae. Osteopenia, especially when severe, indicates defective bone mineralization, as seen in rickets, hypophosphatasia, and osteogenesis imperfecta (OI). Abnormally dense bones may indicate one of the craniotubular disorders such as pyknodysostosis and osteopetrosis. In the neonate, bones are normally sclerotic and the medullary cavity narrowed. Distinguishing abnormally dense bones from normal neonatal sclerosis can be difficult.
Multiple joint dislocations are a salient and persistent feature of some dysplasias. A standard skeletal survey frequently includes only frontal views of the skeleton, which may make it difficult to identify joint dislocations, especially in the infant. The elbow is frequently involved in the setting of dislocations secondary to a dysplasia. Dedicated lateral views are recommended when dislocation is clinically suspected.
After all radiologic findings have been established, a gamut search of some or all of these abnormalities, in conjunction with the clinical findings, may lead to the specific diagnosis. If the “group” of dysplasias has been established, then the specific diagnosis can often be made by referring to a differential diagnosis table such as that developed by Taybi and Lachman.
This group includes thanatophoric dwarfism and achondroplasia. The former is probably the most common lethal skeletal dysplasia and the latter the most common skeletal dysplasia. The group includes the milder variant called hypochondroplasia , and homozygous achondroplasia, which is similar to thanatophoria.
A common genetic locus (4p16.3) is involved. Differing allelic mutations are the cause of the variable severity of expression. The protein encoded is FGFR3, which governs the velocity of endochondral growth. Although long believed that achondroplasia and thanatophoria were caused by loss of function mutations, the mutation in this group actually results in an upmodulation of FGFR3 activity, which is inversely related to the velocity of endochondral growth.
There are common radiologic features in this group. FGFR3 slows endochondral bone growth, so long bones are short. However, it does not affect overall bone thickness because of normal membranous ossification. Therefore long bones are relatively thick. The fibula is usually longer than the tibia. Femoral necks are short and broadened and have a peculiar scooped-out appearance. It is seen as an ovoid lucency of femoral necks, as if an ice cream scoop was radiographed en face. The finding can be seen in all forms of thanatophoria. It is well seen in achondroplasia but not in most forms of hypochondroplasia.
In the normal individual, on a frontal radiograph, the horizontal distance between the pedicles of the vertebral bodies should widen moving inferiorly. FGFR3 group abnormalities exhibit narrowing in the interpediculate distance in the lumber spine. The decrease in the velocity of endochondral ossification also causes platyspondyly. Brachydactyly of all the bones of the hand is present. Because soft tissues are relatively unaffected, fingers are splayed into the “trident configuration.”
Platyspondyly
Narrow sacrosciatic notch
Interpediculate narrowing
Short, thick long bones
Ovoid lucency at femoral necks (scooped out appearance)
Frontal bossing
Trident hands
Fibula longer than tibia
Given the lethality of this dysplasia, it is aptly named after Thanatos, the Greek god of death ( Thanatophoria , meaning “death loving”).
Type 1 includes “cloverleaf skull,” caused by in utero craniosynostosis, and curved long bones. The femurs have a “French telephone receiver” appearance. The type 2 variant has straight long bones and no craniosynostosis.
Platyspondyly is severe. The vertebral bodies are described as U -shaped or H -shaped on an anteroposterior projection.
Skull: proportionately large skull in relation to the body, narrow skull base, cloverleaf skull (type 1 only)
Thorax: long, narrow trunk; very short ribs; handlebar clavicles
Spine: severely flattened, small vertebral bodies with round anterior ends
Pelvis: small, flared iliac bones; very narrow sacrosciatic notches; flat, dysplastic acetabula
Extremities: generalized micromelia; ovoid lucency of femoral necks, round proximal femoral metaphyses with medial spike, curved long bones (type 1 only)
Patients with achondroplasia have normal mentation and a normal or near normal lifespan. As in other members of the FGFR3 family, long bones are short and thick. Interpediculate narrowing is present. In infancy, femoral necks have a scooped out appearance. Since the sacrosciatic notches are narrowed, the pelvic inlet has an appearance of a wide-mouthed champagne glass.
Except for the portions of the occipital bone that form the margin of the foramen magnum, all the bones of the skull are formed by membranous ossification. This results in an enlarged forehead and is termed frontal bossing . In contrast, the foramen magnum is narrowed and can cause cervicomedullary compression.
Skull: enlarged, with significant midface hypoplasia; hydrocephalus rarely present; small skull base with tight foramen magnum
Thorax: small; shortened and anteriorly splayed ribs
Spine: short pedicles with decreased interpediculate distance most marked in the lumbar spine moving downward; posterior vertebral body scalloping, gibbus deformity
Pelvis: round iliac wings with lack of flaring (elephant ear–shaped), flattened acetabular roofs, narrow sacrosciatic notches with champagne glass shaped pelvic inlet
Extremities: rhizomelic micromelia
Hands: brachydactyly with trident hands
Knees: central deep notch in growth plates (Chevron deformity)
Hips: proximal femoral ovoid lucency (infancy); hemispheric capital femoral epiphyses, short femoral necks
Legs: prominent tibial tubercle apophyseal region, fibula overgrowth
Arms: Cortical hyperostosis at deltoid insertion on anterolateral humerus
In hypochondroplasia, radiographic and clinical findings are less severe compared with achondroplasia, and the diagnosis can be challenging. Stature is slightly shortened but is highly variable and may be normal given the range of normal stature in society. Radiographically, aside from shortening of the long bones, interpediculate narrowing is the most sensitive finding.
Type 2 collagen is present in cartilaginous epiphyses and in the vitreous humor. Therefore abnormalities of collagen 2 manifest with platyspondyly due to lack of normal growth at the vertebral ring apophysis, a general delay in epiphyseal ossification, and myopia. Cleft palate completes the phenotypic picture.
Platyspondyly
Delay in epiphyseal ossification most apparent in femoral heads
Cleft palate
Myopia
Short stature
Occipitoatlantal or atlantodental instability
The combination of platyspondyly and short long bones make SEDC a good example of short-limbed, short-trunk dwarfism. It is also a good model for an epiphyseal dysplasia. Ossification in the vertebral bodies begins in the fetus at the lower thoracic spine and progresses superiorly and inferiorly. The cervical spine ossifies last. The normal cervical spine vertebrae at birth are slightly dorsally wedged and are small. In infants with SEDC, the cervical vertebral bodies show little or no ossification. Thoracic and lumbar bodies are, however, small, dorsally wedged, and anteriorly rounded (pear- or oval-shaped), similar in appearance to the cervical spine in the normal infant. In childhood, characteristic central beaks, typical of epiphyseal delay, may be seen. In the adult, vertebral bodies are flattened with irregular end plates.
At birth, no ossification of the talus, calcaneus, or the epiphyses at the knee is present. Normally, the talus and the calcaneus ossify at 20 to 24 weeks' gestation and the epiphyses at about 36 weeks' gestation.
One salient feature is that the hands and feet in patients with SEDC are normal, apart from carpal, midfoot, and hindfoot ossification delay.
Thorax: small; short ribs
Spine: dorsally wedged or oval vertebral bodies (at birth); anteriorly rounded platyspondyly (later)
Pelvis: absent pubic ossification (at birth and during infancy), vertical ischia with short ilia
Extremities: normal tubulization with mild micromelia, significant generalized ossification delay (early), and hypoplastic-appearing or dysplastic epiphyses (later), unossified talus or calcaneus in the newborn, normal hands and feet with ossification delay (epiphyses or carpal, tarsal)
The same delay in epiphyseal ossification is seen along with platyspondyly. Cloudlike dystrophic calcification is present in abnormally enlarged epiphyses as the child gets older. On magnetic resonance imaging (MRI), the areas of calcification have prolonged T2 values that are likely related to the degeneration of abnormal collagen matrix.
Thorax: small to normal
Spine: coronal clefts (at birth and during infancy), platyspondyly with endplate irregularity (later)
Extremities: dumbbell femurs; generalized ossification delay, epiphyses becoming hypoplastic or dysplastic and then later even mega-epiphyses, cloudlike irregular calcification in physeal plate regions (in late childhood and early adulthood); hands with bulbous joints (metaphyseal flaring or epiphyseal fragmentation) mimicking rheumatoid arthritis
Note: In the newborn, Kniest syndrome is radiographically identical to SEDC except for coronal clefts and dumbbell femurs.
Members of this group include Stickler syndrome type 2, Marshall syndrome, oto-spondylo-mega-epiphyseal dysplasia (OSMED), autosomal-dominant type (Weisenbach-Zweymuller phenotype and Stickler type 3).
The multiple synonyms and names applied to the different members of the group cause some confusion. Stickler syndrome type 2 is a type 11 collagenopathy and has a similar appearance to Stickler syndrome type 1 (see type 2 collagenopathy previously discussed) with milder ocular changes and more severe auditory changes. It is autosomal recessive. Marshall syndrome is very similar to Stickler syndrome type 2 and may be considered, for all practical purposes, the same entity.
OSMED autosomal-dominant type is a type 11 collagenopathy as well. It is also called nonocular Stickler syndrome , Stickler syndrome type 3, or Weisenbach-Zweymuller syndrome . Osseous changes in OSMED are usually worse with greater shortening of the long bones and platyspondyly.
Adding to the confusion is a very similar form of Stickler syndrome, which is a type 9 collagenopathy. The similarity is not coincidental. Type 11 and type 2 collagens along with type 9 collagen form collagen fibrils so that the phenotypic expression of a type 2, type 11, or type 9 collagenopathy may be similar. This is an important point in the phenotypic expression of genetic abnormalities. Because the tissues of the body are constructed of multiple elements, differing genetic and biochemical abnormalities may have similar outcomes when considering the end results of the tissues produced.
In practice, when faced with a case with a resemblance to a mild or intermediate severity type 2 or type 11 collagenopathy, both paths should be investigated.
Similar to type 2 collagenopathy
Cleft palate
Sensorineural hearing loss
Myopia (except for Stickler type 3)
Epiphyseal dysplasia (may be large or mildly flattened)
Early arthritis
Platyspondyly
The abnormal sulfation group is a molecularly defined group of disorders with a defect in the sulfate transporter gene on chromosome 5 coding for the diastrophic dysplasia sulfate transporter (DTDST) protein. This group comprises not only diastrophic dysplasia but also a form of MED as well as achondrogenesis type IB and atelosteogenesis type II. These conditions are all autosomal recessive, and the severity of the phenotype is inversely related to the level of sulfation.
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