What are the differential diagnoses for metaphyseal transverse bands (growth‑arrest lines) in children and adolescents?

Differential Diagnosis for Metaphyseal Bands in Children and Adolescents

Metaphyseal transverse bands (growth arrest/recovery lines) in children most commonly represent physiological responses to systemic stress, but you must systematically exclude serious pathology including rickets, scurvy, copper deficiency, osteomyelitis, and child abuse before attributing them to benign causes.

Primary Physiological Considerations

Growth recovery lines (Park-Harris lines) often represent normal developmental responses rather than pure pathology. These radiodense metaphyseal bands develop from temporary interruptions in endochondral ossification and correlate with normal growth spurts and growth hormone secretion patterns 1, 2. However, their presence warrants systematic evaluation for underlying stressors.

Critical Pathological Causes to Exclude First

Rickets (Vitamin D Deficiency)

• Rickets produces metaphyseal changes but with distinctly different radiographic features than simple growth arrest lines 3
• Look for: demineralization, loss of zone of provisional calcification, widening and irregularity of physis, fraying and cupping of metaphysis 3
• Key distinction: In rickets with fractures, metaphyseal fractures occur closer to the diaphysis in the background of florid rachitic changes and do NOT resemble the juxtaphyseal corner or bucket-handle pattern 3
• Rickets is uncommon despite high prevalence of vitamin D insufficiency in infants 3

Scurvy (Vitamin C Deficiency)

• Scurvy can produce metaphyseal changes mimicking abuse but has pathognomonic additional features 3
• Characteristic findings include: osteopenia, increased sclerosis of zones of provisional calcification, dense epiphyseal rings, extensive calcification of subperiosteal and soft tissue hemorrhages 3
• Rare today but consider in infants given exclusively cow milk without vitamin supplementation 3

Copper Deficiency

• Copper deficiency produces metaphyseal changes with distinctive features: cupping and fraying of metaphyses, sickle-shaped metaphyseal spurs, significant demineralization, and subperiosteal new bone formation 3
• Consider in preterm infants <28 weeks gestation or <1500g, those on prolonged total parenteral nutrition (≥4 weeks), or with severe nutritional disorders 3
• Associated findings: psychomotor retardation, hypotonia, hypopigmentation, sideroblastic anemia 3
• Not likely in full-term infants <6 months or preterm infants <2.5 months due to adequate fetal copper stores 3

Menkes Disease

• X-linked recessive copper metabolism defect occurring only in boys 3
• Metaphyseal fragmentation and subperiosteal new bone formation may be difficult to distinguish from abuse 3
• Distinctive features: sparse kinky hair, calvarial wormian bones, anterior rib flaring, failure to thrive, developmental delay, tortuous cerebral vessels 3

Osteomyelitis

• Osteomyelitis in infants presents as multiple metaphyseal irregularities potentially resembling growth arrest lines 3
• Key distinguishing features: lesions become progressively lytic and sclerotic with substantial subperiosteal new bone formation 3
• Associated systemic signs: fever, elevated ESR, elevated CRP, elevated WBC 3

Child Abuse Considerations

Growth recovery lines are significantly more prevalent in abused infants, appearing in 71% of high-risk versus 38% of low-risk infants 4. This suggests abused infants experience episodic physiological stresses causing temporary disturbances in endochondral ossification 4.

• Multiple growth arrest lines should raise suspicion for psychosocial short stature or occult abuse 5
• Consider abuse when lines occur with: classic metaphyseal lesions (corner/bucket-handle fractures), rib fractures, or other high-specificity injuries 3
• Important: Vitamin D insufficiency does NOT cause skeletal lesions leading to incorrect abuse diagnosis and is NOT associated with multiple fractures, rib fractures, or classic metaphyseal lesions 3

Benign/Physiological Causes

Post-Traumatic/Post-Stress Recovery

• Growth arrest lines develop after significant physiological stress including infection, malnutrition, or trauma 1, 6, 5
• Lines mark temporary growth interruption with subsequent recovery 1
• Intra-epiphyseal arrest silhouettes can occur after significant knee trauma (ACL/PCL injuries, tibial spine fractures) 6

Osteopenia of Prematurity

• Affects infants <28 weeks gestation or <1500g birth weight 3
• Risk factors: prolonged total parenteral nutrition (≥4 weeks), bronchopulmonary dysplasia, prolonged diuretics or steroids 3
• Typically presents between 6-12 weeks of life 3
• Fractures usually occur in first year of life; bone density normalizes after first year 3

Disuse Demineralization

• Children with severe disabilities limiting ambulation are at risk for fractures from disuse demineralization with normal handling 3
• Fractures are usually diaphyseal rather than metaphyseal 3

Clinical Algorithm for Evaluation

1. Obtain detailed history focusing on:

   • Dietary history (exclusive cow milk, vitamin supplementation) 3
   • Prematurity and NICU course 3
   • Recent significant illness or physiological stress 1
   • Developmental milestones and growth patterns 3
   • Social circumstances and caregiver concerns 5, 4

2. Perform targeted laboratory evaluation:

   • 25-hydroxyvitamin D level 3
   • Alkaline phosphatase 3
   • Calcium, phosphorus 3
   • Copper and ceruloplasmin if risk factors present 3
   • Vitamin C level if dietary history concerning 3
   • Inflammatory markers (ESR, CRP, WBC) if infection suspected 3

3. Radiographic assessment:

   • Evaluate for additional metaphyseal changes (cupping, fraying, sclerosis) 3
   • Assess for other fractures or skeletal injuries 3
   • Look for characteristic patterns of specific conditions 3

4. Consider child protection evaluation if:

   • Multiple unexplained fractures present 3
   • Classic metaphyseal lesions identified 3
   • Clinical history inconsistent with findings 4
   • Multiple growth arrest lines without clear physiological explanation 5

Critical Pitfalls to Avoid

• Do not attribute metaphyseal bands to vitamin D insufficiency alone—this does not cause the high-specificity fracture patterns seen in abuse 3
• Do not dismiss findings in preterm infants—they are at increased risk for both osteopenia AND abuse 3
• Do not assume recent trauma explains all findings—malignancy must not be prevented from appropriate diagnostic procedures 7
• Recognize that growth arrest lines may represent normal growth spurts rather than pathology, but systematic exclusion of serious causes is mandatory 2